Provider Demographics
NPI:1992289391
Name:PALACIOS, MIRYAN FLOR (RDH)
Entity type:Individual
Prefix:
First Name:MIRYAN
Middle Name:FLOR
Last Name:PALACIOS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22055 46TH AVE APT 1H
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3606
Mailing Address - Country:US
Mailing Address - Phone:347-665-6275
Mailing Address - Fax:
Practice Address - Street 1:4143 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3805
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028831124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist