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General NPI Number Information
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NPI Number | 1649506353
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Entity Type | Organization
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Legal Business Name | X COLLADO DENTAL CENTER
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Dates
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Enumeration Date | 10/30/2009
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Last Update Date | 10/30/2009
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Provider Practice Location Address
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Address Line | 10105 77TH ST
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City | OZONE PARK
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State | NY
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Zip | 11416-1904
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Country | US
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Telephone | 718-323-1288
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Fax | 718-323-0291
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Provider Business Mailing Address
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Address Line | 10105 77TH ST
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City | OZONE PARK
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State | NY
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Zip | 11416-1904
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Country | US
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Telephone | 718-323-1288
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Fax | 718-323-0291
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Authorized Official
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Title or Position | X COLLADO DENTAL CENTER
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Name | JUANA X COLLADO-MEDINA
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Credential | D.D.S
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Telephone | 718-323-1288
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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 | 045798-1
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License Number State | NY
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