Provider Demographics
NPI:1083991822
Name:QUEENS MODERN DENTAL
Entity Type:Organization
Organization Name:QUEENS MODERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:SAINT PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-217-8700
Mailing Address - Street 1:21820 HEMPSTEAD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1235
Mailing Address - Country:US
Mailing Address - Phone:718-217-8700
Mailing Address - Fax:718-217-8706
Practice Address - Street 1:21820 HEMPSTEAD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1235
Practice Address - Country:US
Practice Address - Phone:718-217-8700
Practice Address - Fax:718-217-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0509251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02584774Medicaid