Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 12006549A | IN |
NPI | 1073637450 |
---|---|
Provider Name | Charles Y. Coghlan |
First Address | Bloomington, IN 47401-9726 |
Second Address | Bloomington, IN 47401-6320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2007 |
Last Update Date | 08/07/2007 |