Provider Demographics
NPI:1700135076
Name:DELGADO, LUIS RENE (DMD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RENE
Last Name:DELGADO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 KENNEDY BLVD
Mailing Address - Street 2:APT 419
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-3223
Mailing Address - Country:US
Mailing Address - Phone:787-378-9360
Mailing Address - Fax:
Practice Address - Street 1:1940 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5221
Practice Address - Country:US
Practice Address - Phone:718-583-6347
Practice Address - Fax:718-583-8047
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-02
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0563741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery