Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN008955 | GA |
NPI | 1174603013 |
---|---|
Provider Name | Dr. John Paul Mistretta |
First Address | Atlanta, GA 30303 |
Second Address | Atlanta, GA 30303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00170717E | (05) | GA |
00170717K | (05) | GA |
00170717R | (05) | GA |