Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DNF000334 | GA |
NPI | 1134280829 |
---|---|
Provider Name | Ulf Me Wikesjo |
First Address | Augusta, GA 30912-0004 |
Second Address | Augusta, GA 30912-1001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 25/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1418385 | TRICARE (01) | GA |
555026389A | (05) | GA |
ZG0334 | (05) | SC |