Healthcare Provider Details

I. General information

NPI: 1649206749
Provider Name (Legal Business Name): EROL AGI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH 48 MDG/SGHC UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

PSC 827 BOX 525
FPO AE
09617
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8124
  • Fax:
Mailing address:
  • Phone: 6296004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number043512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: