Provider Demographics
NPI:1497282768
Name:SIERRA-VASQUEZ, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:SIERRA-VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 CONNETQUOT AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-1804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:798 CONNETQUOT AVE
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-1804
Practice Address - Country:US
Practice Address - Phone:631-338-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0416131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program