Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 42920 | CA |
NPI | 1114283033 |
---|---|
Provider Name | Clark Izu |
First Address | Irvine, CA 92606-1739 |
Second Address | Irvine, CA 92606-1739 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2012 |
Last Update Date | 04/04/2012 |