Provider Demographics
NPI:1669859294
Name:LIL PEARLS PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:LIL PEARLS PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-241-9760
Mailing Address - Street 1:94-11 65TH RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94-11 65TH RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374
Practice Address - Country:US
Practice Address - Phone:347-682-5688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056689-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03634535Medicaid