Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 060451 | NY |
NPI | 1073053880 |
---|---|
Provider Name | Laura Wysocki |
First Address | Bronx, NY 10467-2401 |
Second Address | Bronx, NY 10467-2401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2017 |
Last Update Date | 17/09/2020 |