=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295103208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUSTIN R. SOLIS DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2015
-----------------------------------------------------
Last Update Date | 09/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 JERICHO TPKE
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-307-1050
-----------------------------------------------------
Fax | 516-307-1052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 192 JERICHO TPKE
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-307-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DUSTIN R SOLIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 516-307-1050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 053183
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------