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General NPI Number Information
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NPI Number | 1710246533
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Entity Type | Organization
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Legal Business Name | GOTHAM ORAL & MAXILLOFACIAL SURGERY P.C.
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Dates
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Enumeration Date | 05/14/2012
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Last Update Date | 05/14/2012
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Provider Practice Location Address
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Address Line | 563 E TREMONT AVE
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City | BRONX
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State | NY
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Zip | 10457-4655
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Country | US
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Telephone | 718-466-4500
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Fax | 917-792-8502
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Provider Business Mailing Address
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Address Line | 563 E TREMONT AVE
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City | BRONX
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State | NY
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Zip | 10457-4655
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Country | US
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Telephone | 718-466-4500
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Fax | 917-792-8502
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELEFTHERIOS GAVRIIL
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Credential | DDS
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Telephone | 718-466-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 053186
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License Number State | NY
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