Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D13370 | MN |
N | 1223D0001X | Dental Public Health | D13370 | MN |
NPI | 1518379288 |
---|---|
Provider Name | Dr. Mclean Severson |
First Address | Aitkin, MN 56431 |
Second Address | Aitkin, MN 56431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2014 |
Last Update Date | 25/01/2018 |