Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019028738 | IL |
NPI | 1003172081 |
---|---|
Provider Name | Megan Boyd |
First Address | Peoria, IL 61614-4791 |
Second Address | Peoria, IL 61614-4791 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2012 |
Last Update Date | 04/04/2012 |