Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 021001398 | IL |
NPI | 1104925908 |
---|---|
Provider Name | Stephen R Sabol |
First Address | Urbana, IL 61801-2500 |
Second Address | Urbana, IL 61801-2500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2006 |
Last Update Date | 12/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T38565 | (02) | |
T38565 | (02) | IL |