Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DN011807 | GA |
NPI | 1255385696 |
---|---|
Provider Name | Dr. Roman M Cibirka |
First Address | Augusta, GA 30912-0002 |
Second Address | Augusta, GA 30912-0002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ZG1807 | (05) | SC |