Healthcare Provider Details

I. General information

NPI: 1932318730
Provider Name (Legal Business Name): MRS. LARISA NIDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 BRIGHTON BEACH AVE
BROOKLYN NY
11235-5572
US

IV. Provider business mailing address

1120 BRIGHTON BEACH AVE
BROOKLYN NY
11235-5572
US

V. Phone/Fax

Practice location:
  • Phone: 718-996-6978
  • Fax:
Mailing address:
  • Phone: 718-996-6978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number022950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: