Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 30.026051 | OH |
Y | 1223P0221X | Pediatric Dentist | 30.026051 | OH |
NPI | 1033677851 |
---|---|
Provider Name | Mitchell Andrew Poole |
First Address | Columbus, OH 43205-2664 |
Second Address | Columbus, OH 43205-2664 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2019 |
Last Update Date | 06/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0392799 | (05) | OH |