Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 041604 | NY |
NPI | 1073813838 |
---|---|
Provider Name | Dr. Gisella Mortelliti |
First Address | Manlius, NY 13104-9420 |
Second Address | Manlius, NY 13104-9420 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2010 |
Last Update Date | 27/10/2010 |