Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 4919 | WI |
NPI | 1063418416 |
---|---|
Provider Name | Steven R Chybowski |
First Address | Oak Creek, WI 53154-8344 |
Second Address | Oak Creek, WI 53154-8344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2005 |
Last Update Date | 10/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38393100 | (05) | WI |
BC6321311 | DEA (01) | WI |