Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 18383-875 | WI |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 18383-875 | WI |
NPI | 1053962654 |
---|---|
Provider Name | Dr. Flavio De Alcantara Camejo |
First Address | Milwaukee, WI 53233-2186 |
Second Address | Milwaukee, WI 53233-2186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2019 |
Last Update Date | 25/09/2019 |