Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 6402 | OK |
NPI | 1003170887 |
---|---|
Provider Name | Dr. Joshua Allen Mayo |
First Address | Ada, OK 74820-3439 |
Second Address | Ada, OK 74820-3439 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2012 |
Last Update Date | 18/05/2015 |