=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285021568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN YESENIA MILLA ESCOBAR DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2015
-----------------------------------------------------
Last Update Date | 09/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1841 W RIDGE RD ERIE CANAL COMMONS
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14615-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-650-1078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1796 CRITTENDEN RD APT #6
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14623-1432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-650-1078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 058613-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------