Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902017522 | MI |
NPI | 1053855643 |
---|---|
Provider Name | Amanda Thaxton |
First Address | Sturgis, MI 49091-1991 |
Second Address | Sturgis, MI 49091-1991 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2016 |
Last Update Date | 15/12/2016 |