Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 6538 | LA |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 061202 | NY |
NPI | 1083031553 |
---|---|
Provider Name | Sergei A Kuznetsov |
First Address | Brooklyn, NY 11215-2520 |
Second Address | Brooklyn, NY 11235-3292 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2014 |
Last Update Date | 14/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1083031553 | DENTAL (01) | NY |