Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1285155077 |
---|---|
Provider Name | Kori Mansel |
First Address | Brookings, OR 97415-8313 |
Second Address | Brookings, OR 97415-2533 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2017 |
Last Update Date | 30/06/2017 |