Provider Demographics
NPI:1487883534
Name:FUENTES COSMETIC FACILITY INC.
Entity type:Organization
Organization Name:FUENTES COSMETIC FACILITY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDIDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-385-9381
Mailing Address - Street 1:120 NEW YORK AVE
Mailing Address - Street 2:SUITE 1W
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2743
Mailing Address - Country:US
Mailing Address - Phone:631-385-9381
Mailing Address - Fax:
Practice Address - Street 1:120 NEW YORK AVE
Practice Address - Street 2:1W
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2743
Practice Address - Country:US
Practice Address - Phone:631-385-9381
Practice Address - Fax:631-385-4372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX ID