Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1356437024 |
---|---|
Provider Name | Jenny S. Russell |
First Address | Ellington, MO 63638-0579 |
Second Address | Ellington, MO 63638 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 08/07/2007 |