=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205833639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDOUARD SORKIN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1939 MCCULLOCH BLVD N
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-855-5041
-----------------------------------------------------
Fax | 928-855-2757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1939 MCCULLOCH BLVD N
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-855-5041
-----------------------------------------------------
Fax | 928-855-2757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5157
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------