=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962662262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZINAMIT LUCKSOM-GARCIA D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 12/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 W 4TH ST
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10550-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-699-7200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 DEXTER AVE
-----------------------------------------------------
City | PEARL RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10965-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 22DI02408800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS037792
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 056593
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------