Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 0515411 | NY |
N | 1223X0400X | Orthodontists | 22DI02309200 | NJ |
NPI | 1023154341 |
---|---|
Provider Name | Dr. Russell Sandman |
First Address | New York, NY 10019-2509 |
Second Address | Jamaica, NY 11432-5523 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02778912 | (05) | NY |