Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DNO12589 | GA |
NPI | 1003995390 |
---|---|
Provider Name | Dr. Jessy Koshy |
First Address | Atlanta, GA 30350-1887 |
Second Address | Atlanta, GA 30350-1887 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 08/07/2007 |