Healthcare Provider Details

I. General information

NPI: 1669204665
Provider Name (Legal Business Name): MICHAEL DAVID VILLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15406 JEWEL AVE APT 3C
FLUSHING NY
11367-1846
US

IV. Provider business mailing address

15406 JEWEL AVE APT 3C
FLUSHING NY
11367-1846
US

V. Phone/Fax

Practice location:
  • Phone: 347-552-6661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number064134
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number027079
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI03015600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: