Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 016.0002044 | VT |
NPI | 1023093606 |
---|---|
Provider Name | Murray Diner |
First Address | Newport, VT 05855 |
Second Address | Richford, VT 05476-1151 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2005 |
Last Update Date | 10/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1006289 | (05) | VT |