Provider Demographics
NPI:1104183078
Name:MERCADO, VICTOR A (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:A
Last Name:MERCADO
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 1:10533 DITMARS BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-1634
Mailing Address - Country:US
Mailing Address - Phone:347-231-9266
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-8573
Practice Address - Fax:718-492-5090
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0567511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice