Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 22D101983800 | NJ |
NPI | 1013010529 |
---|---|
Provider Name | Mr. Alexander Yermolenko |
First Address | Hillside, NJ 07205 |
Second Address | Hillside, NJ 07205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7280505 | (05) | NJ |