Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 2901021011 | MI |
N | 1223S0112X | Oral and Maxillofacial Surgeon | S157 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | 4301119400 | MI |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 67345 | MN |
NPI | 1154760932 |
---|---|
Provider Name | John Salek-Raham |
First Address | North Oaks, MN 55127-3025 |
Second Address | North Oaks, MN 55127-3025 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2013 |
Last Update Date | 20/10/2020 |