Provider Demographics
NPI:1477051787
Name:SAN MIGUEL, CAMILLE SUZETTE (DDS)
Entity Type:Individual
Prefix:MISS
First Name:CAMILLE
Middle Name:SUZETTE
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CATHERINE ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-1049
Mailing Address - Country:US
Mailing Address - Phone:240-491-7171
Mailing Address - Fax:
Practice Address - Street 1:8708 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2284
Practice Address - Country:US
Practice Address - Phone:718-805-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0612591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry