Provider Demographics
NPI:1578640074
Name:LEUWAISEE, PETAL CANDACE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:PETAL
Middle Name:CANDACE
Last Name:LEUWAISEE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 E 108TH ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3055
Mailing Address - Country:US
Mailing Address - Phone:718-649-0818
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE9 QQ
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:121-299-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022881124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist