Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | D1839 | AZ |
N | 1223D0001X | Dental Public Health | D1839 | AZ |
N | 1223G0001X | General Practice | D1839 | AZ |
N | 213EG0000X | General Practice | D1839 | AZ |
NPI | 1235228966 |
---|---|
Provider Name | Marc Braslow |
First Address | Tempe, AZ 85283-3794 |
Second Address | Tempe, AZ 85283-3794 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D1839 | AZ STATE (01) | AZ |