Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 039330 | NY |
NPI | 1114070075 |
---|---|
Provider Name | Dr. Robert James Sicurelli JR. |
First Address | Southampton, NY 11968-3014 |
Second Address | Southampton, NY 11968-3014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 08/07/2007 |