Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 12633 | FL |
NPI | 1093886772 |
---|---|
Provider Name | Mr. William D. Mcgrady |
First Address | Fort Myers, FL 33907-5638 |
Second Address | Fort Myers, FL 33907-5638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12633 | DENTAL LICENSE (01) | FL |