Provider Demographics
NPI:1467677054
Name:CALDERON, MARCELO EDUARDO (DMD,PC)
Entity Type:Individual
Prefix:DR
First Name:MARCELO
Middle Name:EDUARDO
Last Name:CALDERON
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13501 LEFFERTS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3601
Mailing Address - Country:US
Mailing Address - Phone:718-845-6297
Mailing Address - Fax:718-845-6563
Practice Address - Street 1:13501 LEFFERTS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3601
Practice Address - Country:US
Practice Address - Phone:718-845-6297
Practice Address - Fax:718-845-6563
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041073-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006709OtherLOCATION # DORAL
NY01124010Medicaid