Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 2994 | WI |
NPI | 1225191067 |
---|---|
Provider Name | Dr. Ezedin M Sadeghi |
First Address | Fox Point, WI 53217-2332 |
Second Address | Fox Point, WI 53217-2332 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 08/07/2007 |