Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN12820 | FL |
NPI | 1013036664 |
---|---|
Provider Name | Mark J. Tenniswood |
First Address | Okeechobee, FL 34972-2947 |
Second Address | Okeechobee, FL 34972-2947 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2007 |
Last Update Date | 08/07/2007 |