Basic Information
| Provider Information | |||||||||
| NPI: | 1386618544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALOMEQUE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4079058998 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327033208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4078802138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 02/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN11858 | FL | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 029547796 | 01 | FL | MEDICAID DENTAL | OTHER | BP1756812 | 01 | FL | DEA | OTHER | 029547700 | 01 | FL | MEDICAID FQHC | OTHER | 057724300 | 01 | FL | MEDICAID FEE FOR SERVICE | OTHER | 075996100 | 05 | FL | MEDICAID |