Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2012015480 | MO |
NPI | 1003177601 |
---|---|
Provider Name | Dr. Dominique Glennon Harter |
First Address | Cape Girardeau, MO 63703-5015 |
Second Address | Cape Girardeau, MO 63703-5015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2012 |
Last Update Date | 02/07/2014 |