Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | DDS-09722 | IA |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DDS09722 | IA |
NPI | 1073937223 |
---|---|
Provider Name | Brock Radich |
First Address | Des Moines, IA 50321-3105 |
Second Address | Des Moines, IA 50321-3105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2014 |
Last Update Date | 15/05/2020 |