Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | DN22199 | MA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DS030512L | PA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN22199 | MA |
NPI | 1184609018 |
---|---|
Provider Name | Edward Vanisky |
First Address | Burlington, MA 01803-5154 |
Second Address | Burlington, MA 01803-5115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 09/05/2019 |