Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 3201 | SC |
N | 122300000X | Dentist | 6817 | KY |
N | 1223P0300X | Periodontist | DN13450 | FL |
NPI | 1154448629 |
---|---|
Provider Name | James William Betancourt |
First Address | Vero Beach, FL 32960-5200 |
Second Address | Vero Beach, FL 32960-5200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U66159 | (02) | FL |