Healthcare Provider Details

I. General information

NPI: 1578055950
Provider Name (Legal Business Name): MICHELE JACLYN EQUINDA DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 HARRISON ST
NEW YORK NY
10013-2890
US

IV. Provider business mailing address

15 HARRISON ST
NEW YORK NY
10013-2890
US

V. Phone/Fax

Practice location:
  • Phone: 212-758-0040
  • Fax:
Mailing address:
  • Phone: 516-672-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number059708
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019.030585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: