Provider Demographics
NPI:1932505963
Name:PALACIO, JOHANNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:PALACIO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W 60TH ST STE 1GH
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 W 60TH ST STE 1GH
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7902
Practice Address - Country:US
Practice Address - Phone:212-246-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057419-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist