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Individual
KENNETH DORSEY TISDALE
Active
Individual
KENNETH DORSEY TISDALE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
L.C.I.C.I., LMT #548
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
LMT # 5488
NM
Other
Enumeration date
02/28/2011
Last updated
02/28/2011
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