Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | MO |
NPI | 1306961263 |
---|---|
Provider Name | Miss Mary Amanda Thompson |
First Address | St Louis, MO 63129 |
Second Address | St Louis, MO 63119 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 08/07/2007 |