Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 52037 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | 11973 | MN |
NPI | 1275500076 |
---|---|
Provider Name | David J Rallis |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2006 |
Last Update Date | 23/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
343643800 | (05) | MN |
ENROLLED | (05) | MN |
V04496 | (02) |