Provider Demographics
NPI:1346412459
Name:CENTRO DENTAL DRA. REYES PLLC
Entity Type:Organization
Organization Name:CENTRO DENTAL DRA. REYES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIOLA
Authorized Official - Middle Name:ANTILLANA
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-740-2800
Mailing Address - Street 1:1569 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4261
Mailing Address - Country:US
Mailing Address - Phone:212-740-2800
Mailing Address - Fax:212-740-1900
Practice Address - Street 1:1569 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4261
Practice Address - Country:US
Practice Address - Phone:212-740-2800
Practice Address - Fax:212-740-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048089261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01926416Medicaid