=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063724714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AURA DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2010
-----------------------------------------------------
Last Update Date | 07/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7011 108TH ST
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-4448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-544-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7011 108TH ST
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-4448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-544-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GEORGE SEPIASHVILI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-544-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 048450
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------