Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DN008930 | GA |
NPI | 1093718645 |
---|---|
Provider Name | Dr. Robert Carl Wunderle |
First Address | Marietta, GA 30068-5518 |
Second Address | Marietta, GA 30068-5518 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 10/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U22592 | (02) | GA |