Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 10099 | GA |
NPI | 1043481609 |
---|---|
Provider Name | Dr. Sally Young |
First Address | Statesboro, GA 30458-4712 |
Second Address | Statesboro, GA 30458-2118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2008 |
Last Update Date | 21/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00328314B | (05) | GA |