MEDICARE: CONSOLACION SOBERANO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	045753	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1223G0001X	OTHER	NY	DENTIST

General Provider Information

NPI Number	:	1316947476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSOLACION SOBERANO DDS

Provider Business Mailing Address
First Line	:	19 PEPPER CIR E
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-3509
Country	:	US
Telephone Number	:	718-945-7150
Fax Number	:

Provider Business Practice Location Address
First Line	:	6710 ROCKAWAY BEACH BLVD
Second Line	:
City	:	ARVERNE
State	:	NY
Zip	:	11692-1271
Country	:	US
Telephone Number	:	718-945-7150
Fax Number	:	718-327-8336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	07/08/2007

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