Provider Demographics
NPI:1972947349
Name:IZQUIERDO, PATRICIA M (DDS)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:IZQUIERDO
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 1:41-94 DENMAN STREET
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-960-6628
Mailing Address - Fax:
Practice Address - Street 1:183RD STREET THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-960-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1972947349Medicaid