Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DS029194L | PA |
NPI | 1083700793 |
---|---|
Provider Name | Michelle Icasiano |
First Address | Fort Benning, GA 31905 |
Second Address | Fort Benning, GA 31905 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 08/07/2007 |