Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 7984 | KY |
N | 1223P0221X | Pediatric Dentist | 7984 | KY |
NPI | 1043433758 |
---|---|
Provider Name | Dr. John Douglas Page |
First Address | Tompkinsville, KY 42167 |
Second Address | Tompkinsville, KY 42167 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 19/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
60002268 | (05) | KY |