Provider Demographics
NPI:1972029742
Name:QUEENS DENTAL SLEEP MEDICINE, LLC
Entity Type:Organization
Organization Name:QUEENS DENTAL SLEEP MEDICINE, LLC
Other - Org Name:KOALA CENTER FOR SLEEP DISORDERS NY-2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:W
Authorized Official - Last Name:ENG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-683-9040
Mailing Address - Street 1:11825 N. STATE ROUTE 40
Mailing Address - Street 2:STE 100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525
Mailing Address - Country:US
Mailing Address - Phone:309-376-8385
Mailing Address - Fax:
Practice Address - Street 1:3560 74TH ST # 103A
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-4316
Practice Address - Country:US
Practice Address - Phone:718-683-9040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty