Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | IL |
NPI | 1083768113 |
---|---|
Provider Name | Philip Nelson |
First Address | Chicago, IL 60631-3817 |
Second Address | Chicago, IL 60631-3817 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2007 |
Last Update Date | 08/07/2007 |