Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 5032-015 | WI |
Y | 122300000X | Dentist | 7909 | CO |
NPI | 1003895996 |
---|---|
Provider Name | Brent Eric Havey |
First Address | Peterson Afb, CO 80914-1540 |
Second Address | Peterson Afb, CO 80914-1540 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2006 |
Last Update Date | 13/03/2009 |