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General NPI Number Information
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NPI Number | 1629366703
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL WORLD, PC
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Dates
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Enumeration Date | 07/11/2011
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Last Update Date | 07/11/2011
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Provider Practice Location Address
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Address Line | 7228 BROADWAY 2ND FLOOR
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-6331
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Country | US
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Telephone | 718-478-2825
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Fax | 718-478-2831
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Provider Business Mailing Address
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Address Line | 7228 BROADWAY 2ND FLOOR
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-6331
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Country | US
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Telephone | 718-478-2825
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Fax | 718-478-2831
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Authorized Official
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Title or Position | OWNER
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Name | DR. DESIREE LARACUENTE
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Credential | DMD
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Telephone | 718-478-2825
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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 | 053544
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License Number State | NY
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