Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019014128 | IL |
NPI | 1003897950 |
---|---|
Provider Name | Dr. John S Paige JR. |
First Address | Wolf Point, MT 59201-6000 |
Second Address | Wolf Point, MT 59201-6000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 02/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019014128 | (05) | IL |