Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 6043 | AL |
NPI | 1003248899 |
---|---|
Provider Name | Dr. Kyle Minter Parks |
First Address | Flagstaff, AZ 86004-7600 |
Second Address | Tuba City, AZ 86045 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2013 |
Last Update Date | 02/08/2013 |