Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 2016018480 | MO |
Y | 122300000X | Dentist | 61219 | KS |
NPI | 1003266966 |
---|---|
Provider Name | Dr. Lorenzo Kidd Neilsen |
First Address | Lees Summit, MO 64081-4040 |
Second Address | Lees Summit, MO 64081-4040 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2016 |
Last Update Date | 07/08/2016 |