Provider Demographics
NPI:1053427377
Name:CORDERO, DAMARIS ALTAGRACIA (DDS)
Entity type:Individual
Prefix:
First Name:DAMARIS
Middle Name:ALTAGRACIA
Last Name:CORDERO
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 1:2925 GRAND CONCOURSE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1707
Mailing Address - Country:US
Mailing Address - Phone:718-329-4111
Mailing Address - Fax:718-329-1614
Practice Address - Street 1:2925 GRAND CONCOURSE
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1707
Practice Address - Country:US
Practice Address - Phone:718-329-4111
Practice Address - Fax:718-329-1614
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0458101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01544421Medicaid