Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 019020034 | IL |
NPI | 1003977224 |
---|---|
Provider Name | Mr. Edward Paul Rentschler |
First Address | Rockford, IL 61107 |
Second Address | Rockford, IL 61107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 28/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T38652 | (02) | IL |