Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN22364 | FL |
N | 122300000X | Dentist | DS031205L | PA |
NPI | 1003012212 |
---|---|
Provider Name | Dr. Mark Gaponiuk |
First Address | Vero Beach, FL 32962-4312 |
Second Address | Vero Beach, FL 32962-4312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2007 |
Last Update Date | 21/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DN22364 | STATE LICENSE (01) | FL |