Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 30776 | CA |
NPI | 1063058824 |
---|---|
Provider Name | Jade Rose Puckett |
First Address | Livingston, CA 95334-9593 |
Second Address | Livingston, CA 95334-9593 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/11/2019 |
Last Update Date | 26/11/2019 |