Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 027779 | NY |
NPI | 1518028166 |
---|---|
Provider Name | Stuart Super |
First Address | New York, NY 10021-7215 |
Second Address | New York, NY 10021-7215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 08/07/2007 |