Provider Demographics
NPI:1154474161
Name:ARCHER-FESTA, MAUREEN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:A
Last Name:ARCHER-FESTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 NASSAU DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2158
Mailing Address - Country:US
Mailing Address - Phone:516-829-8965
Mailing Address - Fax:516-498-9364
Practice Address - Street 1:3755 76TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6507
Practice Address - Country:US
Practice Address - Phone:718-429-6116
Practice Address - Fax:718-429-0843
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY40213-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01578156Medicaid