Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 6091-15 | WI |
Y | 1223E0200X | Endodontist | 021.002068 | IL |
NPI | 1063693315 |
---|---|
Provider Name | Dr. Edward Bruce Noakes III |
First Address | Rockford, IL 61107 |
Second Address | Rockford, IL 61107-6819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2007 |
Last Update Date | 15/11/2007 |