=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528321312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. TAJUL ISLAM DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COMMUNITY DR SUITE C-2
-----------------------------------------------------
City | TOBYHANNA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18466-8978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-974-4775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 COMMUNITY DR SUITE C-2
-----------------------------------------------------
City | TOBYHANNA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18466-8978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-974-4775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TAJUL ISLAM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-974-4775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DS038535
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------