Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 9412 | GA |
NPI | 1023109378 |
---|---|
Provider Name | Dr. Laura C Durham |
First Address | Griffin, GA 30224-4862 |
Second Address | Griffin, GA 30224-4862 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00345078A | (05) | GA |