1437469459 NPI number — JUAN CARLOS DEFEX, DDS PLLC

Table of content: (NPI 1437469459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437469459 NPI number — JUAN CARLOS DEFEX, DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUAN CARLOS DEFEX, DDS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437469459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7410 35TH AVE
Provider Second Line Business Mailing Address:
SUITE 106W
Provider Business Mailing Address City Name:
JACKSON HEIGHTS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11372-8197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-476-6750
Provider Business Mailing Address Fax Number:
718-426-4040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7410 35TH AVE
Provider Second Line Business Practice Location Address:
SUITE 106W
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-8197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-476-6750
Provider Business Practice Location Address Fax Number:
718-426-4040
Provider Enumeration Date:
10/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DEFEX
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
CARLOS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-476-6750

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  043060-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01407450 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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