Provider Demographics
NPI:1245525351
Name:PESANTES DENTAL PC
Entity type:Organization
Organization Name:PESANTES DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PESANTES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-850-1011
Mailing Address - Street 1:11109 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2323
Mailing Address - Country:US
Mailing Address - Phone:718-850-1011
Mailing Address - Fax:718-850-6086
Practice Address - Street 1:11109 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2323
Practice Address - Country:US
Practice Address - Phone:718-850-1011
Practice Address - Fax:718-850-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0464611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01738614Medicaid