Provider Demographics
NPI:1518172113
Name:JUAN COLLADO, DDS PC
Entity Type:Organization
Organization Name:JUAN COLLADO, DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:PABLO
Authorized Official - Last Name:COLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-568-3231
Mailing Address - Street 1:365 ROCKLEDGE PL
Mailing Address - Street 2:PRIVATE HOUSE
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4014
Mailing Address - Country:US
Mailing Address - Phone:212-568-3231
Mailing Address - Fax:212-568-7727
Practice Address - Street 1:520 W 190TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3407
Practice Address - Country:US
Practice Address - Phone:212-568-3231
Practice Address - Fax:212-568-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045828-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02752707Medicaid