Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019029690 | IL |
Y | 1223E0200X | Endodontist | 021002580 | IL |
NPI | 1124432638 |
---|---|
Provider Name | Dr. Jason Foreman |
First Address | Champaign, IL 61822-6199 |
Second Address | Champaign, IL 61822-6199 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2014 |
Last Update Date | 25/08/2014 |