Provider Demographics
NPI:1962674697
Name:C.LEON VASQUEZ DENTAL SERVICE PC
Entity Type:Organization
Organization Name:C.LEON VASQUEZ DENTAL SERVICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:A
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-507-9731
Mailing Address - Street 1:40-27 69TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3836
Mailing Address - Country:US
Mailing Address - Phone:718-507-9731
Mailing Address - Fax:718-507-2700
Practice Address - Street 1:40-27 69TH ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3836
Practice Address - Country:US
Practice Address - Phone:718-507-9731
Practice Address - Fax:718-507-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01283150Medicaid
NY01283169Medicaid