Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1316435043 |
---|---|
Provider Name | Emily Cannucci |
First Address | Beaverton, OR 97005 |
Second Address | Beaverton, OR 97005-1401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2018 |
Last Update Date | 27/04/2018 |