=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902062821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABRA J. DILISIO D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 05/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3905 61ST ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-899-5437
-----------------------------------------------------
Fax | 718-247-5727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 E 96TH ST APARTMENT 17A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10128-3839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-217-4590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 054342-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------