Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | D10277 | OR |
NPI | 1073997086 |
---|---|
Provider Name | Katelyn Nichols |
First Address | Salem, OR 97305-1069 |
Second Address | Salem, OR 97305-1069 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2015 |
Last Update Date | 20/07/2015 |