Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019016282 | IL |
Y | 1223P0300X | Periodontist | 021001185 | IL |
NPI | 1134261951 |
---|---|
Provider Name | Dr. Timothy Dee Aiossa |
First Address | Elmwood Park, IL 60707-4140 |
Second Address | Elmwood Park, IL 60707-4140 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 15/07/2008 |