Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | A2418 | OR |
NPI | 1104169960 |
---|---|
Provider Name | Lynda Kay Buckner |
First Address | Antigo, WI 54409-1329 |
Second Address | Antigo, WI 54409-1329 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2013 |
Last Update Date | 30/03/2013 |