Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 19019741 | IL |
NPI | 1043353493 |
---|---|
Provider Name | Scott Prose |
First Address | St Charles, IL 60174-1442 |
Second Address | St Charles, IL 60174-1442 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 08/07/2007 |