Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 22DI02522100 | NJ |
NPI | 1134519150 |
---|---|
Provider Name | Alexander Volchonok |
First Address | New York, NY 10025-6437 |
Second Address | New York, NY 10025-6437 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2015 |
Last Update Date | 28/01/2015 |