Healthcare Provider Details

I. General information

NPI: 1821052317
Provider Name (Legal Business Name): JUAN CARLOS DE FEX DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74-10 35TH AVENUE SUITE 106W
JACKSON HEIGHTS NY
11372-8160
US

IV. Provider business mailing address

74-10 35TH AVENUE SUITE 106W
JACKSON HEIGHTS NY
11372-8160
US

V. Phone/Fax

Practice location:
  • Phone: 718-476-6750
  • Fax: 718-426-4040
Mailing address:
  • Phone: 718-476-6750
  • Fax: 718-426-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number043060
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: