1417151945 NPI number — DR. NODARI DAVITIASHVILI DDS

Table of content: DR. NODARI DAVITIASHVILI DDS (NPI 1417151945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417151945 NPI number — DR. NODARI DAVITIASHVILI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVITIASHVILI
Provider First Name:
NODARI
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVITI
Provider Other First Name:
NODARI
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417151945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3902 SEDGWICK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10463-4460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-495-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3902 SEDGWICK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10463-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-495-1000
Provider Business Practice Location Address Fax Number:
917-495-1000
Provider Enumeration Date:
06/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0483091 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 010921 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01975048 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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