Healthcare Provider Details

I. General information

NPI: 1164797858
Provider Name (Legal Business Name): VISHAAL AGRAWAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BOND ST STE 8
GREAT NECK NY
11021
US

IV. Provider business mailing address

4540 CENTER BLVD APT 2602
LONG ISLAND CITY NY
11109-5815
US

V. Phone/Fax

Practice location:
  • Phone: 951-751-5779
  • Fax:
Mailing address:
  • Phone: 951-751-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number059956
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: