Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H4342 | AZ |
NPI | 1043479108 |
---|---|
Provider Name | Fred Summerfelt |
First Address | Flagstaff, AZ 86001-6572 |
Second Address | Flagstaff, AZ 86001-6572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2008 |
Last Update Date | 04/06/2008 |