Healthcare Provider Details

I. General information

NPI: 1023220993
Provider Name (Legal Business Name): YOHANNES SYOUM D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 W 120TH ST
NEW YORK NY
10027-6308
US

IV. Provider business mailing address

62 W 120TH ST
NEW YORK NY
10027-6308
US

V. Phone/Fax

Practice location:
  • Phone: 212-289-5349
  • Fax:
Mailing address:
  • Phone: 212-289-5349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045182
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: