Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 6414015 | WI |
NPI | 1063700045 |
---|---|
Provider Name | Alison Mantel |
First Address | Cedarburg, WI 53012-1925 |
Second Address | Cedarburg, WI 53012-1925 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2011 |
Last Update Date | 12/07/2011 |