Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 016083 | MO |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 016083 | MO |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 2005027155 | MO |
N | 208D00000X | General Practice Physician | 2005027155 | MO |
NPI | 1285613240 |
---|---|
Provider Name | Mr. Matthew R Hlavacek |
First Address | Lees Summit, MO 64086-5594 |
Second Address | Lees Summit, MO 64086-5594 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2006 |
Last Update Date | 30/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
204017107 | (05) | MO |
404017105 | (05) | MO |
U05567 | (02) | MO |