Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 104574 | NC |
NPI | 1013025352 |
---|---|
Provider Name | Mr. Tim Mabe |
First Address | Walnut Cove, NC 27052 |
Second Address | Walnute Cove, NC 27052 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8902103 | (05) | NC |
8995436 | UNITED HEALTHCARE (01) |