Provider Demographics
NPI:1437469459
Name:JUAN CARLOS DEFEX, DDS PLLC
Entity Type:Organization
Organization Name:JUAN CARLOS DEFEX, DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:DEFEX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-476-6750
Mailing Address - Street 1:7410 35TH AVE
Mailing Address - Street 2:SUITE 106W
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-8197
Mailing Address - Country:US
Mailing Address - Phone:718-476-6750
Mailing Address - Fax:718-426-4040
Practice Address - Street 1:7410 35TH AVE
Practice Address - Street 2:SUITE 106W
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-8197
Practice Address - Country:US
Practice Address - Phone:718-476-6750
Practice Address - Fax:718-426-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043060-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01407450Medicaid