Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 057492-1 | NY |
Y | 1223E0200X | Endodontist | 057492-1 | NY |
NPI | 1053756205 |
---|---|
Provider Name | Bobak Bakhshoudeh |
First Address | New York, NY 10016-9821 |
Second Address | New York, NY 10017-6819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2013 |
Last Update Date | 29/06/2019 |