Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 1001778-15 | WI |
NPI | 1083870232 |
---|---|
Provider Name | Daniel Young |
First Address | Onalaska, WI 54650-6709 |
Second Address | Onalaska, WI 54650-6709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2008 |
Last Update Date | 28/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
51557703 | (05) | CO |