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General NPI Number Information
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NPI Number | 1679958052
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Entity Type | Organization
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Legal Business Name | QUEENSVILLAGEDENTALCARE,P.C.
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Dates
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Enumeration Date | 07/27/2015
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Last Update Date | 07/27/2015
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Provider Practice Location Address
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Address Line | 22005 94TH DR
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City | QUEENS VILLAGE
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State | NY
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Zip | 11428-2105
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Country | US
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Telephone | 718-465-3265
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Fax | 718-776-4260
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Provider Business Mailing Address
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Address Line | 22005 94TH DR
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City | QUEENS VILLAGE
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State | NY
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Zip | 11428-2105
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Country | US
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Telephone | 718-465-3265
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Fax | 718-776-4260
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TERENCE TEEKAH MAHASE
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Credential | D.D.S
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Telephone | 718-465-3265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 042201
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License Number State | NY
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