Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | IL |
NPI | 1013058809 |
---|---|
Provider Name | Karl Kirby Marine |
First Address | Moline, IL 61265-7826 |
Second Address | Moline, IL 61265-7826 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 08/07/2007 |