Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | STUDENT | OK |
NPI | 1003437757 |
---|---|
Provider Name | Dominique Burdette |
First Address | Skiatook, OK 74070-9404 |
Second Address | Sallisaw, OK 74955-9302 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2020 |
Last Update Date | 05/05/2020 |