Healthcare Provider Details

I. General information

NPI: 1508686437
Provider Name (Legal Business Name): DIANA VANESSA BERNAL-MUNOZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA VANESSA BERNAL-MUNOZ

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 41ST AVE
LONG ISLAND CITY NY
11101-4801
US

IV. Provider business mailing address

14639 14TH AVE APT B3
WHITESTONE NY
11357-2401
US

V. Phone/Fax

Practice location:
  • Phone: 718-784-2240
  • Fax: 914-471-8022
Mailing address:
  • Phone: 929-316-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number007074
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: