Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | IL |
NPI | 1003969809 |
---|---|
Provider Name | Dr. Martin Daniel Bour |
First Address | Frankfort, IL 60423 |
Second Address | Frankfort, IL 60423 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |