Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 1223P0300X | AL |
NPI | 1053572594 |
---|---|
Provider Name | Daniel M Pittman III |
First Address | Dothan, AL 36303-6903 |
Second Address | Dothan, AL 36303-6903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2008 |
Last Update Date | 18/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5430 | STATE OF AL (01) | AL |