Basic Information
Provider Information | |||||||||
NPI: | 1003001207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GORJI | ||||||||
FirstName: | NILOO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 359 MERROW RD | ||||||||
Address2: |   | ||||||||
City: | TOLLAND | ||||||||
State: | CT | ||||||||
PostalCode: | 060843961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608759000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 359 MERROW ROAD | ||||||||
Address2: |   | ||||||||
City: | TOLLAND | ||||||||
State: | CT | ||||||||
PostalCode: | 060843961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608759000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2007 | ||||||||
LastUpdateDate: | 09/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8725 | CT | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.