Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DD5101 | NM |
Y | 1223D0001X | Dental Public Health | DD5101 | NM |
NPI | 1194383752 |
---|---|
Provider Name | Dr. Craig Testerman |
First Address | Edgewood, NM 87015-2980 |
Second Address | Edgewood, NM 87015-7086 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2019 |
Last Update Date | 03/10/2020 |