Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D9060 | OR |
NPI | 1043470479 |
---|---|
Provider Name | Dr. Matt Gebhardt |
First Address | Fort Collins, CO 80525-2507 |
Second Address | Medford, OR 97504-8900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2008 |
Last Update Date | 10/06/2008 |