MEDICARE: QUEENSVILLAGEDENTALCARE,P.C.

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	302R00000X	Health Maintenance Organization	042201	NY

General Provider Information

NPI Number	:	1679958052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEENSVILLAGEDENTALCARE,P.C.

Provider Business Mailing Address
First Line	:	22005 94TH DR
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11428-2105
Country	:	US
Telephone Number	:	718-465-3265
Fax Number	:	718-776-4260

Provider Business Practice Location Address
First Line	:	22005 94TH DR
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11428-2105
Country	:	US
Telephone Number	:	718-465-3265
Fax Number	:	718-776-4260

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TERENCE TEEKAH MAHASE
Credential	:	D.D.S
Telephone Number	:	718-465-3265

Provider Enumeration Date	:	07/27/2015
Last Update Date	:	07/27/2015

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