Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | IL |
NPI | 1023224243 |
---|---|
Provider Name | Dr. Robert J Manasse |
First Address | Matteson, IL 60443-2349 |
Second Address | Matteson, IL 60443-2349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2007 |
Last Update Date | 08/07/2007 |