Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 1001385-15 | WI |
NPI | 1033563606 |
---|---|
Provider Name | Jack Michael Keesler |
First Address | Neenah, WI 54956-5042 |
Second Address | Milwaukee, WI 53233-2186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2016 |
Last Update Date | 06/09/2019 |