Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 08053 | IA |
NPI | 1093825176 |
---|---|
Provider Name | Michael Steven Mathews |
First Address | West Burlington, IA 52655 |
Second Address | West Burlington, IA 52655 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0265975 | (05) | IA |