Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 0013387 | MO |
NPI | 1003929969 |
---|---|
Provider Name | Dr. Vincent Miles Lutterbie |
First Address | Marshall, MO 65340 |
Second Address | Marshall, MO 65340 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8140613 | CPIN (01) | |
T81817 | (02) |