Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 5672 | AL |
Y | 1223G0001X | General Practice | 5672 | AL |
Y | 213EG0000X | General Practice | 5672 | AL |
N | 1223P0106X | Oral and Maxillofacial Pathology | 5672 | AL |
N | 1223P0221X | Pediatric Dentist | 5672 | AL |
N | 1223X0400X | Orthodontists | 5672 | AL |
NPI | 1669602405 |
---|---|
Provider Name | Dr. Jillian K Mckelroy |
First Address | Mobile, AL 36652-2048 |
Second Address | Mobile, AL 36603-5341 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2009 |
Last Update Date | 30/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5672 | ALABAMA STATE LICENSE (01) | AL |