Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0221X | Pediatric Dentist | 00201959 | CO |
Y | 1223P0221X | Pediatric Dentist | 6422 | LA |
NPI | 1023454071 |
---|---|
Provider Name | Dr. Micahel Jason Gambill |
First Address | Bossier City, LA 71111-3465 |
Second Address | Bossier City, LA 71111-3465 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2013 |
Last Update Date | 16/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30872 | (05) | LA |