Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D-4396 | ID |
NPI | 1003182668 |
---|---|
Provider Name | Jessica Faye Horricks |
First Address | Sandpoint, ID 83864-0908 |
Second Address | Bonners Ferry, ID 83805 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2012 |
Last Update Date | 28/03/2012 |