Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | DA0000010658 | TN |
NPI | 1316271638 |
---|---|
Provider Name | Casey Terry |
First Address | Jacksboro, TN 37757-2507 |
Second Address | Jacksboro, TN 37757-2507 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2009 |
Last Update Date | 21/09/2009 |