Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 39349 | CA |
NPI | 1164571220 |
---|---|
Provider Name | Dr. Mark Vidor |
First Address | Long Beach, CA 90803-3946 |
Second Address | Long Beach, CA 90803-3946 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2007 |
Last Update Date | 08/07/2007 |