Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223D0001X | Dental Public Health | D009726 | AZ |
Y | 1223G0001X | General Practice | D009726 | AZ |
Y | 213EG0000X | General Practice | D009726 | AZ |
NPI | 1740718386 |
---|---|
Provider Name | Dr. Geoffery Kalvin Lines |
First Address | Glendale, AZ 85306-4230 |
Second Address | San Luis, AZ 85349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2017 |
Last Update Date | 26/05/2017 |