Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 0401413196 | VA |
N | 213EG0000X | General Practice | 0401413196 | VA |
Y | 1223P0300X | Periodontist | 0401413196 | VA |
NPI | 1073893137 |
---|---|
Provider Name | Dr. Jennette Bick O'bryhim |
First Address | Ft Gordon, GA 30905-5660 |
Second Address | Ft Gordon, GA 30905-5660 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2011 |
Last Update Date | 19/11/2019 |