Provider Demographics
NPI:1699010736
Name:CARRASQUILLO, JEFFREY (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CARRASQUILLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 MAURICE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-7536
Mailing Address - Country:US
Mailing Address - Phone:718-651-5941
Mailing Address - Fax:
Practice Address - Street 1:6625 MAURICE AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-7536
Practice Address - Country:US
Practice Address - Phone:718-651-5941
Practice Address - Fax:718-261-4742
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist