Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 4440 | AL |
NPI | 1013073378 |
---|---|
Provider Name | Dr. Gipson Mark Kingry |
First Address | Montgomery, AL 36116-7205 |
Second Address | Montgomery, AL 36116-7205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2006 |
Last Update Date | 08/07/2007 |