Basic Information
| Provider Information | |||||||||
| NPI: | 1215508098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOCK | ||||||||
| FirstName: | ILAN | ||||||||
| MiddleName: | MOSHE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 860 SUMMIT CROSSING PL STE 110 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048653937 | ||||||||
| FaxNumber: | 7048658851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2021 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2278 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2676 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.