Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1275200677 |
---|---|
Provider Name | Brooke Phelon |
First Address | San Antonio, TX 78216-5834 |
Second Address | San Antonio, TX 78216-5834 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2021 |
Last Update Date | 24/08/2021 |