Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 020-007937 | IL |
NPI | 1053865865 |
---|---|
Provider Name | Gina Marie Misch |
First Address | Chicago, IL 60638-3313 |
Second Address | Chicago, IL 60638-3313 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2016 |
Last Update Date | 09/08/2016 |