Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DN7579 | FL |
NPI | 1114037660 |
---|---|
Provider Name | Robert Powell |
First Address | Pembroke Pines, FL 33024-3603 |
Second Address | Pembroke Pines, FL 33024-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 08/07/2007 |