Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2901016314 | MI |
NPI | 1003899733 |
---|---|
Provider Name | Robert L Eggleston |
First Address | Grandville, MI 49418-2930 |
Second Address | Grandville, MI 49418-2930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2005 |
Last Update Date | 08/07/2007 |