Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 123592 | AK |
N | 1223D0001X | Dental Public Health | 123592 | AK |
NPI | 1669992715 |
---|---|
Provider Name | Camille Humphrey |
First Address | Oracle, AZ 85623-6257 |
Second Address | Bethel, AK 99559-1085 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2017 |
Last Update Date | 03/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
123592 | (05) | AK |