Provider Demographics
NPI:1609261320
Name:QUEENS DENTAL PC
Entity Type:Organization
Organization Name:QUEENS DENTAL PC
Other - Org Name:INWOOD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYORGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-677-2110
Mailing Address - Street 1:85 DOUGHTY BLVD
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-2001
Mailing Address - Country:US
Mailing Address - Phone:516-239-3283
Mailing Address - Fax:516-371-0390
Practice Address - Street 1:85 DOUGHTY BLVD
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2001
Practice Address - Country:US
Practice Address - Phone:516-239-3283
Practice Address - Fax:516-371-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05065011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty