Provider Demographics
NPI:1336290402
Name:VELAZQUEZ, MELVIN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:R
Last Name:VELAZQUEZ
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 1:6 OLD SEARINGTOWN RD
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1533
Mailing Address - Country:US
Mailing Address - Phone:516-742-3111
Mailing Address - Fax:718-898-7473
Practice Address - Street 1:6907 43RD AVE
Practice Address - Street 2:SUITEC1
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-9100
Practice Address - Country:US
Practice Address - Phone:718-898-6010
Practice Address - Fax:718-606-2713
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485987Medicaid