Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 0402207520 | VA |
NPI | 1043784606 |
---|---|
Provider Name | Elizabeth Jene Ezell |
First Address | South Hill, VA 23970 |
Second Address | South Hill, VA 23970 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2019 |
Last Update Date | 17/01/2019 |