MEDICARE: MIRYAN FLOR PALACIOS RDH

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	124Q00000X	Dental Hygienist	028831	NY

General Provider Information

NPI Number	:	1992289391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRYAN FLOR PALACIOS RDH

Provider Business Mailing Address
First Line	:	22055 46TH AVE APT 1H
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3606
Country	:	US
Telephone Number	:	347-665-6275
Fax Number	:

Provider Business Practice Location Address
First Line	:	4143 CRESCENT ST
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3805
Country	:	US
Telephone Number	:	718-784-2240
Fax Number	:

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

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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