Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 4467 | AL |
NPI | 1104908227 |
---|---|
Provider Name | Dr. Charlotte Anne Smith |
First Address | Daphne, AL 36526-7037 |
Second Address | Daphne, AL 36526-7037 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
96999 | BLUE CROSS (01) | AL |