Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 19-A15561 | IL |
NPI | 1003971789 |
---|---|
Provider Name | Dr. Clifford Prince |
First Address | Skokie, IL 60076-3117 |
Second Address | Skokie, IL 60076-3117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/12/2006 |
Last Update Date | 08/07/2007 |