Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | A10895 | WA |
NPI | 1124364344 |
---|---|
Provider Name | Marla Jean Macleod-Martin |
First Address | Stevenson, WA 98648-6423 |
Second Address | Vancouver, WA 98686-1448 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2012 |
Last Update Date | 14/12/2012 |