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General NPI Number Information
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NPI Number | 1376765859
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Entity Type | Organization
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Legal Business Name | JEFFREY CARRASQUILLO DMD PLLC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 11/30/2012
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Provider Practice Location Address
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Address Line | 66-25 MAURICE AVE
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City | WOODSIDE
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State | NY
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Zip | 11372
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Country | US
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Telephone | 718-651-5941
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Fax | 718-261-4742
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Provider Business Mailing Address
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Address Line | 90-05 70TH DRIVE
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City | FOREST HILLS
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State | NY
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Zip | 11375
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Country | US
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Telephone | 718-261-0260
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Fax | 718-261-4742
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY CARRASQUILLO
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Credential | DMD
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Telephone | 718-261-0260
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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 | 045010
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License Number State | NY
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