Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2901011077 | MI |
NPI | 1003974155 |
---|---|
Provider Name | Dr. Walter Knysz JR. |
First Address | Bloomfield Hills, MI 48304 |
Second Address | Dearborn, MI 48128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |