Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 1002255-15 | WI |
NPI | 1063869485 |
---|---|
Provider Name | Tyler Kalmuck |
First Address | Sheboygan, WI 53081-3050 |
Second Address | Sheboygan, WI 53081-3050 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2016 |
Last Update Date | 21/09/2020 |