Provider Demographics
NPI:1386618544
Name:PALOMEQUE, THERESA (DDS)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:PALOMEQUE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:210 E 7TH ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-3208
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-880-2138
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11858122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029547796OtherMEDICAID DENTAL
FL029547700OtherMEDICAID FQHC
FL057724300OtherMEDICAID FEE FOR SERVICE
FL075996100Medicaid
FL075996100Medicaid