Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 136000125 | IL |
NPI | 1104191881 |
---|---|
Provider Name | Dr. Miryam Nathalia Garcia |
First Address | Ballwin, MO 63021-5888 |
Second Address | Alton, IL 62002-4742 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2012 |
Last Update Date | 14/03/2012 |