Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 4802 | LA |
NPI | 1003823782 |
---|---|
Provider Name | Dr. Susie Parker Goolsby |
First Address | Thibodaux, LA 70301-3615 |
Second Address | Thibodaux, LA 70301-3615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1848026 | (05) | LA |