Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 021.001429 | IL |
NPI | 1083863898 |
---|---|
Provider Name | Thomas Barrett Braun |
First Address | Crest Hill, IL 60403 |
Second Address | Crest Hill, IL 60403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2008 |
Last Update Date | 17/09/2008 |