Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 022336 | NY |
NPI | 1063623510 |
---|---|
Provider Name | Johanna Thiesen-Root |
First Address | Albany, NY 12208-1708 |
Second Address | Albany, NY 12208-1708 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00022336 | (05) | NY |