Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 2901018814 | MI |
NPI | 1083782254 |
---|---|
Provider Name | Carolyn Suzanne John |
First Address | Lake Orion, MI 48359-1598 |
Second Address | Lake Orion, MI 48359-1598 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 13/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V02462 | (02) |