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General NPI Number Information
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NPI Number | 1114267283
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Entity Type | Organization
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Legal Business Name | STATE DENTAL ARTS P.C
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Dates
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Enumeration Date | 02/26/2013
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Last Update Date | 02/26/2013
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Provider Practice Location Address
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Address Line | 6715 ROOSEVELT AVE
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City | WOODSIDE
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State | NY
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Zip | 11377
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Country | US
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Telephone | 917-815-5767
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Fax |
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Provider Business Mailing Address
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Address Line | 6715 ROOSEVELT AVE
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City | WOODSIDE
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State | NY
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Zip | 11377
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | MS. LIGIA V STATE
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Credential | DDS
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Telephone | 917-815-5767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 052176
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License Number State | NY
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