Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 046375 | NY |
N | 122300000X | Dentist | D20421 | TX |
NPI | 1003918723 |
---|---|
Provider Name | Dr. Long Su |
First Address | New York, NY 10013-7841 |
Second Address | New York, NY 10013-3501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 15/03/2013 |