Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 101073 | OH |
NPI | 1306235494 |
---|---|
Provider Name | Kristi Archer |
First Address | Fairborn, OH 45324-3647 |
Second Address | Centerville, OH 45459-4295 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2015 |
Last Update Date | 13/01/2015 |