Provider Demographics
NPI:1043805336
Name:AGUILERA AYALA, NICOLAS AUGUSTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:AUGUSTO
Last Name:AGUILERA AYALA
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 1:30 E 76TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2700
Mailing Address - Country:US
Mailing Address - Phone:631-408-2271
Mailing Address - Fax:
Practice Address - Street 1:30 E 76TH ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2700
Practice Address - Country:US
Practice Address - Phone:212-794-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062478-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY874813458Medicaid