Healthcare Provider Details

I. General information

NPI: 1609056068
Provider Name (Legal Business Name): NINA BEATRIZ LARACUENTE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 83RD ST GROUND FLOOR
EAST ELMHURST NY
11370-2007
US

IV. Provider business mailing address

3255 83RD ST GROUND FLOOR
EAST ELMHURST NY
11370-2007
US

V. Phone/Fax

Practice location:
  • Phone: 718-313-0613
  • Fax: 718-535-7815
Mailing address:
  • Phone: 718-313-0613
  • Fax: 718-535-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number050779
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050779
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: