Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902012177 | MI |
NPI | 1033686464 |
---|---|
Provider Name | Katie Jordan |
First Address | Lathrup Village, MI 48076-4518 |
Second Address | Lathrup Village, MI 48076-4518 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2018 |
Last Update Date | 24/10/2018 |