=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053531095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NILES A. SYSKA D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25520 STATE ROAD 46
-----------------------------------------------------
City | SORRENTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32776-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-735-2211
-----------------------------------------------------
Fax | 352-735-5844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25520 STATE ROAD 46
-----------------------------------------------------
City | SORRENTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32776-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-735-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30021205
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN17296
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------