Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | $$$$$$$$$ | NY |
NPI | 1184170722 |
---|---|
Provider Name | Mr. Dominique Marrow |
First Address | Apo, AE 09180 |
Second Address | Apo, AE 09180 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 01/09/2016 |