Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 036444-1 | NY |
NPI | 1144283391 |
---|---|
Provider Name | Theodore Lax |
First Address | Elmira, NY 14901-3220 |
Second Address | Elmira, NY 14901-3220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036444-1 | (05) | NY |