Provider Demographics
NPI:1790816551
Name:ANDRADE, JORGE ALBERTO (DDS)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ALBERTO
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MINEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2002
Mailing Address - Country:US
Mailing Address - Phone:516-484-3937
Mailing Address - Fax:
Practice Address - Street 1:535 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-4217
Practice Address - Country:US
Practice Address - Phone:516-883-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045879-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice