Healthcare Provider Details

I. General information

NPI: 1255356325
Provider Name (Legal Business Name): PAUL WESELEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E 19TH ST
BROOKLYN NY
11229-3540
US

IV. Provider business mailing address

1950 E 19TH ST
BROOKLYN NY
11229-3540
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-5202
  • Fax: 718-336-5205
Mailing address:
  • Phone: 718-336-5202
  • Fax: 718-336-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number028741
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: