Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 31704 | CA |
NPI | 1003922956 |
---|---|
Provider Name | Dr. Keith Evan Serxner |
First Address | La Canada, CA 91011-3438 |
Second Address | La Canada, CA 91011-3438 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31704 | LICENSE (01) | CA |