Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 015787 | MO |
NPI | 1063610392 |
---|---|
Provider Name | Dr. Dwight E. Mcleod |
First Address | Hazelwood, MO 63042-4107 |
Second Address | Hazelwood, MO 63042-4107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2007 |
Last Update Date | 09/07/2007 |