Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 059765 | NY |
NPI | 1134512171 |
---|---|
Provider Name | Scott Peters |
First Address | Merrick, NY 11566-5546 |
Second Address | New York, NY 10032 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2015 |
Last Update Date | 16/07/2018 |