Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2779 | OK |
NPI | 1013453935 |
---|---|
Provider Name | Jamie Horacek |
First Address | Ft. Sill, OK 73503 |
Second Address | Lawton, OK 73507-9030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2017 |
Last Update Date | 17/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
124Q00000X | HYGIENE (01) | OK |