Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 11292 | FL |
NPI | 1043323223 |
---|---|
Provider Name | George M Kazakos |
First Address | Fort Myers, FL 33919-3506 |
Second Address | Fort Myers, FL 33919-3506 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U05652 | (02) | FL |