Provider Demographics
NPI:1780870261
Name:QUISQUEYA DENTAL
Entity type:Organization
Organization Name:QUISQUEYA DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-847-8807
Mailing Address - Street 1:11310 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2440
Mailing Address - Country:US
Mailing Address - Phone:718-847-8807
Mailing Address - Fax:718-847-9464
Practice Address - Street 1:11310 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2440
Practice Address - Country:US
Practice Address - Phone:718-847-8807
Practice Address - Fax:718-847-9464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUISQUEYA DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051596-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02579899Medicaid