Healthcare Provider Details

I. General information

NPI: 1699773036
Provider Name (Legal Business Name): SOCORRO AMAGO BENEDICTO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 149TH PL
FLUSHING NY
11354-4942
US

IV. Provider business mailing address

4017 149TH PL
FLUSHING NY
11354-4942
US

V. Phone/Fax

Practice location:
  • Phone: 718-939-4027
  • Fax: 718-939-4121
Mailing address:
  • Phone: 718-939-4027
  • Fax: 718-939-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number32503
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: