Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 126800000X | Dental Assistant |
NPI | 1184183279 |
---|---|
Provider Name | Ericka Travis |
First Address | Canton, MS 39046-3535 |
Second Address | Yazoo City, MS 39194-4008 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2019 |
Last Update Date | 11/06/2019 |