Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D10121 | OR |
N | 122300000X | Dentist | DD4838 | NM |
NPI | 1003225236 |
---|---|
Provider Name | Dan Lafferty JR. |
First Address | Jacksonville, FL 32212 |
Second Address | Albuquerque, NM 87111-2565 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2014 |
Last Update Date | 18/08/2020 |