Provider Demographics
NPI:1174702609
Name:FERGUSON, PATRICE DIANNA (DDS)
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:DIANNA
Last Name:FERGUSON
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 1:770 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4535
Mailing Address - Country:US
Mailing Address - Phone:516-868-8781
Mailing Address - Fax:718-949-2035
Practice Address - Street 1:770 IMPERIAL DR
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4535
Practice Address - Country:US
Practice Address - Phone:516-868-8781
Practice Address - Fax:718-949-2035
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist