Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | LA2472 | LA |
NPI | 1003988239 |
---|---|
Provider Name | Dr. Eddy Waller Sherman |
First Address | Summerfield, LA 71079 |
Second Address | Summerfield, LA 71079 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1824721 | (05) | LA |