Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 015864 | MO |
NPI | 1063591089 |
---|---|
Provider Name | Dr. Mark Allen Massey |
First Address | Springfield, MO 65810-2658 |
Second Address | Springfield, MO 65810-2658 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 08/07/2007 |