Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 06120 | IA |
NPI | 1003052861 |
---|---|
Provider Name | Dr. Mark W Recker |
First Address | Pella, IA 50219-1434 |
Second Address | Pella, IA 50219-1434 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2008 |
Last Update Date | 29/12/2008 |