Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | IL |
NPI | 1003917915 |
---|---|
Provider Name | Lisa Mostowfi Konz |
First Address | Libertyville, IL 60048 |
Second Address | Libertyville, IL 60048 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 08/07/2007 |