Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist |
NPI | 1619329307 |
---|---|
Provider Name | Kenneth Hortman |
First Address | Roberta, GA 31078-0900 |
Second Address | Roberta, GA 31078-4866 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2016 |
Last Update Date | 06/07/2016 |