Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 2117 | AZ |
NPI | 1013126101 |
---|---|
Provider Name | Dr. Raymond Mcready Travis Vanderwerf |
First Address | Mesa, AZ 85204-6657 |
Second Address | Mesa, AZ 85204-6657 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2007 |
Last Update Date | 08/07/2007 |