Provider Demographics
NPI:1447709761
Name:QDG DENTAL, PC
Entity type:Organization
Organization Name:QDG DENTAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:QIAO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-248-2946
Mailing Address - Street 1:13107 40TH RD
Mailing Address - Street 2:E30
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5116
Mailing Address - Country:US
Mailing Address - Phone:718-353-3332
Mailing Address - Fax:
Practice Address - Street 1:13107 40TH RD
Practice Address - Street 2:E30
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5116
Practice Address - Country:US
Practice Address - Phone:718-353-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03119977Medicaid