Provider Demographics
NPI:1164584470
Name:ANTONIO, WILMA F (DR)
Entity Type:Individual
Prefix:DR
First Name:WILMA
Middle Name:F
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:WILMA
Other - Middle Name:P
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:57 W 57TH STREET
Mailing Address - Street 2:SUITE 1414
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:212-752-8431
Mailing Address - Fax:212-752-9718
Practice Address - Street 1:57 W 57 ST
Practice Address - Street 2:STE 1414
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-752-8431
Practice Address - Fax:212-752-9718
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist