=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568796746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMRITA PERSAUD D.D.S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2009
-----------------------------------------------------
Last Update Date | 06/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8034 222ND ST
-----------------------------------------------------
City | QUEENS VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-862-1509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8034 222ND ST
-----------------------------------------------------
City | QUEENS VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11427-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-862-1509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 054650
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------