Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 019022138 | IL |
NPI | 1568514248 |
---|---|
Provider Name | Mark W Lingen |
First Address | Chicago, IL 60637-1447 |
Second Address | Burr Ridge, IL 60527-5965 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 26/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019022138 | (05) | IL |