Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0700X | Prosthodontist | 019-023546 | IL |
Y | 1223P0700X | Prosthodontist | 12011162A | IN |
NPI | 1083852669 |
---|---|
Provider Name | Roland S. Outarsingh |
First Address | Munster, IN 46321-1649 |
Second Address | Munster, IN 46321-1649 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2009 |
Last Update Date | 12/02/2009 |