Provider Demographics
NPI:1720275936
Name:AGUDELO, LILIANA SOFIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LILIANA
Middle Name:SOFIA
Last Name:AGUDELO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 MORRISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310
Mailing Address - Country:US
Mailing Address - Phone:718-727-4770
Mailing Address - Fax:
Practice Address - Street 1:528 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-965-4549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01238619Medicaid