Provider Demographics
NPI:1720129661
Name:SEGURITAN, MIKHAIL ROEL (DDS)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:ROEL
Last Name:SEGURITAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 W 58TH ST
Mailing Address - Street 2:2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1630
Mailing Address - Country:US
Mailing Address - Phone:212-688-2452
Mailing Address - Fax:212-223-8126
Practice Address - Street 1:57 W 58TH ST
Practice Address - Street 2:2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1630
Practice Address - Country:US
Practice Address - Phone:212-688-2452
Practice Address - Fax:212-223-8126
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045789122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice