Provider Demographics
NPI:1629157250
Name:STATE, LIGIA V (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIGIA
Middle Name:V
Last Name:STATE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 91ST ST
Mailing Address - Street 2:APT#C21
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-3663
Mailing Address - Country:US
Mailing Address - Phone:917-815-5767
Mailing Address - Fax:
Practice Address - Street 1:423 E 138TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-3004
Practice Address - Country:US
Practice Address - Phone:718-292-3800
Practice Address - Fax:718-292-3803
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0521761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02701559Medicaid