Provider Demographics
NPI:1245636331
Name:JUAN C JARAMILLO DDS PC
Entity type:Organization
Organization Name:JUAN C JARAMILLO DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:LUCIA
Authorized Official - Last Name:PALACIO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:347-204-3914
Mailing Address - Street 1:8470 129TH ST
Mailing Address - Street 2:APT 2B
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 WEST 60TH STREET
Practice Address - Street 2:SUITE 1GH
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-246-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057419-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty