Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 43696 | CA |
NPI | 1073660346 |
---|---|
Provider Name | Jennifer Goss |
First Address | Roseville, CA 95661-3408 |
Second Address | Roseville, CA 95661-3408 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2007 |
Last Update Date | 17/02/2009 |