Provider Demographics
NPI:1033227798
Name:DENTAL AMERICA PC
Entity Type:Organization
Organization Name:DENTAL AMERICA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIO
Authorized Official - Middle Name:GERARDO
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-533-1515
Mailing Address - Street 1:8114 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3757
Mailing Address - Country:US
Mailing Address - Phone:718-533-1515
Mailing Address - Fax:718-289-6508
Practice Address - Street 1:81 14 QUEENS BLVD.
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-533-1515
Practice Address - Fax:718-289-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0411621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9200032OtherDORAL DENTAL IPA OF NY
NY01435776Medicaid