Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN17195 | FL |
NPI | 1093750630 |
---|---|
Provider Name | Dr. Edward Jordan Tarver IV |
First Address | Lakeland, FL 33803 |
Second Address | Lakeland, FL 33803 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BT 9412785 | DEA (01) | FL |
DN17195 | LICENSE NUMBER (01) | FL |