Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 08906 | IA |
Y | 122300000X | Dentist | 7198 | NE |
NPI | 1003175837 |
---|---|
Provider Name | Jane Lea Wachter |
First Address | Ravenna, NE 68869-1363 |
Second Address | Ravenna, NE 68869-1363 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2012 |
Last Update Date | 20/08/2015 |