Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DN015388 | GA |
NPI | 1174984165 |
---|---|
Provider Name | Eric Bailey |
First Address | Buford, GA 30518-3480 |
Second Address | Buford, GA 30518 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2016 |
Last Update Date | 25/07/2019 |