Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 11036 | TN |
NPI | 1003474909 |
---|---|
Provider Name | Jamie Trott |
First Address | Cleveland, TN 37312-2970 |
Second Address | Cleveland, TN 37312-2970 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2019 |
Last Update Date | 05/06/2019 |