Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN011355 | GA |
N | 122300000X | Dentist | DNO11355 | GA |
N | 1223D0001X | Dental Public Health | DNO11355 | GA |
NPI | 1700077922 |
---|---|
Provider Name | William Bruce Fink |
First Address | Canton, GA 30114-9719 |
Second Address | Woodstock, GA 30189-8274 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2007 |
Last Update Date | 02/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1700077922 | COMMERCIAL PAYERS (01) | GA |