Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 20522 | TX |
NPI | 1033351408 |
---|---|
Provider Name | Bryan Elvebak |
First Address | Plano, TX 75093-6392 |
Second Address | Plano, TX 75093-6392 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/04/2009 |
Last Update Date | 01/04/2009 |