Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 6179-15 | WI |
NPI | 1295916419 |
---|---|
Provider Name | Mr. Matt R Agnew |
First Address | Madison, WI 53713-4226 |
Second Address | Sun Prairie, WI 53590-1930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2007 |
Last Update Date | 04/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33815700 | (05) | WI |