Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | IL |
NPI | 1043384076 |
---|---|
Provider Name | Dr. John W. Distel |
First Address | Barrington, IL 60010-6833 |
Second Address | Barrington, IL 60010-6833 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2006 |
Last Update Date | 08/07/2007 |