Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 11554-16 | WI |
NPI | 1043684079 |
---|---|
Provider Name | Tyler Server |
First Address | Milwaukee, WI 53218-2552 |
Second Address | Milwaukee, WI 53218-2552 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2015 |
Last Update Date | 13/11/2015 |