Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1154928869 |
---|---|
Provider Name | Marcy Munday |
First Address | Colorado Springs, CO 80951-4756 |
Second Address | Colorado Springs, CO 80914-2900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2020 |
Last Update Date | 06/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
15030223705 | TRICARE (01) |