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General NPI Number Information
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NPI Number | 1477754851
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL CONCEPTS OF QUEENS, PLLC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 11/13/2007
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Provider Practice Location Address
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Address Line | 176-60 UNION TPKE SUITE 120
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City | FLUSHING
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State | NY
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Zip | 11366-1531
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Country | US
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Telephone | 718-969-1701
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Fax | 718-969-1058
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Provider Business Mailing Address
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Address Line | 17660 UNION TPKE SUITE 120
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City | FLUSHING
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State | NY
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Zip | 11366-1531
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Country | US
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Telephone | 718-969-1701
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Fax | 718-969-1058
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SILVESTRO IOMMAZZO JR.
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Credential | DDS
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Telephone | 718-969-1701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 044312
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License Number State | NY
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