Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 010888 | GA |
NPI | 1225250822 |
---|---|
Provider Name | Dr. Wilburn Taylor Dominy JR. |
First Address | Peachtree City, GA 30269-3367 |
Second Address | Peachtree City, GA 30269-3367 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 08/07/2007 |