Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 104878 | CO |
NPI | 1003933862 |
---|---|
Provider Name | Dr. Ricky Eugene Harrell |
First Address | Broomfield, CO 80020-8275 |
Second Address | Aurora, CO 80045-7238 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2007 |
Last Update Date | 08/07/2007 |