Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 905103 | CO |
NPI | 1023302338 |
---|---|
Provider Name | Laura Lee Spencer-Wagner |
First Address | Mancos, CO 81328-9190 |
Second Address | Mancos, CO 81328-9190 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2011 |
Last Update Date | 30/09/2012 |