Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 22DI01911700 | NJ |
NPI | 1003020512 |
---|---|
Provider Name | Dr. Basiliso Paterno Tiu |
First Address | Edgewater, NJ 07020 |
Second Address | Edgewater, NJ 07020 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 08/07/2007 |