Provider Demographics
NPI:1033328950
Name:CERVANTES GRUNDY, JORGE MIGUEL (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:MIGUEL
Last Name:CERVANTES GRUNDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 VERMILYEA AVE
Mailing Address - Street 2:SUITE #27
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034
Mailing Address - Country:US
Mailing Address - Phone:212-567-1729
Mailing Address - Fax:212-567-0909
Practice Address - Street 1:145 VERMILYEA AVE
Practice Address - Street 2:SUITE #27
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034
Practice Address - Country:US
Practice Address - Phone:212-567-1729
Practice Address - Fax:212-567-0909
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0366151223G0001X
NJ1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223P0700XDental ProvidersDentistProsthodontics