Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D2097 | ID |
NPI | 1124139134 |
---|---|
Provider Name | Dr. Michael John Bingham |
First Address | Boise, ID 83704-4447 |
Second Address | Boise, ID 83704-4447 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |