Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 16954 | CA |
NPI | 1184780660 |
---|---|
Provider Name | Dr. Jack Olen Mills |
First Address | Livermore, CA 94550-4148 |
Second Address | Livermore, CA 94550-4148 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2006 |
Last Update Date | 08/07/2007 |