Provider Demographics
NPI:1912321126
Name:GHALILI, KAMBIZ
Entity Type:Individual
Prefix:
First Name:KAMBIZ
Middle Name:
Last Name:GHALILI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 WEST 55TH STREET
Mailing Address - Street 2:SUIT 305
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:212-581-5360
Mailing Address - Fax:
Practice Address - Street 1:65 W 55TH ST
Practice Address - Street 2:EAST 70TH STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4913
Practice Address - Country:US
Practice Address - Phone:212-581-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKG1133OtherDENTISTRY