Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist |
NPI | 1275295081 |
---|---|
Provider Name | Mr. Charles Joseph Hortman JR. |
First Address | Forsyth, GA 31029-2156 |
Second Address | Forsyth, GA 31029-2156 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/10/2021 |
Last Update Date | 08/10/2021 |