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General NPI Number Information
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NPI Number | 1609261320
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Entity Type | Organization
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Legal Business Name | QUEENS DENTAL PC
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 85 DOUGHTY BLVD
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City | INWOOD
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State | NY
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Zip | 11096-2001
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Country | US
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Telephone | 516-239-3283
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Fax | 516-371-0390
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Provider Business Mailing Address
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Address Line | 85 DOUGHTY BLVD
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City | INWOOD
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State | NY
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Zip | 11096-2001
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Country | US
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Telephone | 516-239-3283
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Fax | 516-371-0390
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Authorized Official
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Title or Position | MANAGER
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Name | MS. ERICKA MAYORGA
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Credential |
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Telephone | 347-677-2110
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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 | 0506501
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License Number State | NY
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