Provider Demographics
NPI:1558402123
Name:CORDERO, FERNANDO (DMD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:CORDERO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6148 62ND AVE
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1009
Mailing Address - Country:US
Mailing Address - Phone:718-417-7766
Mailing Address - Fax:718-417-1305
Practice Address - Street 1:589 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4742
Practice Address - Country:US
Practice Address - Phone:718-366-9191
Practice Address - Fax:718-417-1305
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0508741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02471772Medicaid