Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 4274 | LA |
NPI | 1548391444 |
---|---|
Provider Name | Dr. Philip G Driscoll |
First Address | Browning, MT 59417 |
Second Address | Browning, MT 59417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 31/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4274 | STATE DENTAL LICENSE (01) | LA |