Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | D13719 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | 29838 | MN |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 68180 | MN |
NPI | 1083078554 |
---|---|
Provider Name | Marvin Vallejo |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2016 |
Last Update Date | 15/09/2020 |