Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 48747 | CA |
N | 1223P0300X | Periodontist | 56 | OK |
NPI | 1083695100 |
---|---|
Provider Name | Robert Mcleod |
First Address | Costa Mesa, CA 92627-4653 |
Second Address | Costa Mesa, CA 92627-4653 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2005 |
Last Update Date | 11/07/2008 |