Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | D12007 | MN |
NPI | 1184731648 |
---|---|
Provider Name | Juan Vesga |
First Address | Minneapolis, MN 55404-3074 |
Second Address | Minneapolis, MN 55404-3074 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 08/07/2007 |