Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 10490 | TN |
NPI | 1013673193 |
---|---|
Provider Name | Kristen Rothery |
First Address | Knoxville, TN 37922-0621 |
Second Address | Knoxville, TN 37922-0621 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2021 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10490 | DENTAL HYGIENE LICENSE (01) | TN |