Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DD4981 | NM |
NPI | 1104142470 |
---|---|
Provider Name | Dr. Elizaveta V Rogol |
First Address | New York, NY 10023-1823 |
Second Address | Albuquerque, NM 87102-4516 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2010 |
Last Update Date | 25/09/2018 |