Provider Demographics
NPI:1952390015
Name:COLLADO, JUAN PABLO (DDS)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:PABLO
Last Name:COLLADO
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 1:520 W 190TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3407
Mailing Address - Country:US
Mailing Address - Phone:212-568-3231
Mailing Address - Fax:212-568-7727
Practice Address - Street 1:520 W 190TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3407
Practice Address - Country:US
Practice Address - Phone:212-568-3231
Practice Address - Fax:212-568-7727
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01539651Medicaid