Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 01917449 | IL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 019.017449 | IL |
NPI | 1144387275 |
---|---|
Provider Name | Dr. Herbert Dennis Stith |
First Address | Geneva, IL 60134-3911 |
Second Address | Geneva, IL 60134-3911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/01/2007 |
Last Update Date | 16/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
792720 | (02) | IL |