Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | OK |
NPI | 1316397300 |
---|---|
Provider Name | Michelle Mcdermott |
First Address | Fort Sill, OK 73503 |
Second Address | Fort Sill, OK 73503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2016 |
Last Update Date | 12/07/2016 |