Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 021.003109 | IL |
NPI | 1124518188 |
---|---|
Provider Name | Wiley Yao |
First Address | Marshfield, WI 54449-8855 |
Second Address | Homewood, IL 60430-2597 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2018 |
Last Update Date | 28/09/2021 |