Provider Demographics
NPI:1689731051
Name:FACEY, MAXINE MARIA
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:MARIA
Last Name:FACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E MOSHOLU PKWY N
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2625
Mailing Address - Country:US
Mailing Address - Phone:718-652-7370
Mailing Address - Fax:
Practice Address - Street 1:55 E MOSHOLU PKWY N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2625
Practice Address - Country:US
Practice Address - Phone:718-652-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024237124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist