Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1033584826 |
---|---|
Provider Name | Lori Groves |
First Address | Austell, GA 30168-7459 |
Second Address | Birmingham, AL 35233-1927 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2015 |
Last Update Date | 06/12/2015 |