Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | CO5131 | CO |
NPI | 1124109491 |
---|---|
Provider Name | Michael G Wiley |
First Address | Colorado Springs, CO 80918-1984 |
Second Address | Colorado Springs, CO 80918-1984 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 08/07/2007 |