Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 6633-015 | WI |
NPI | 1063710655 |
---|---|
Provider Name | Dr. Erik Daniel Deyoung |
First Address | Wauwatosa, WI 53213-2983 |
Second Address | Wauwatosa, WI 53213-2983 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2011 |
Last Update Date | 05/03/2011 |