Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DRPM2189 | FL |
Y | 1223E0200X | Endodontist | DN25420 | FL |
NPI | 1134746738 |
---|---|
Provider Name | Dr. Cody Parker Bertoch |
First Address | Gainesville, FL 32610-0436 |
Second Address | Gainesville, FL 32610-0436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2020 |
Last Update Date | 09/06/2021 |