Provider First Line Business Practice Location Address:
24-16 QUEENS PLAZA SOUTH
Provider Second Line Business Practice Location Address:
IGOR PORT DDS
Provider Business Practice Location Address City Name:
LIC
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-205-2020
Provider Business Practice Location Address Fax Number:
914-242-8599
Provider Enumeration Date:
09/13/2012