Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1114915576 |
---|---|
Provider Name | Mr. Ray Ball |
First Address | Bellevue, NE 68123 |
Second Address | Offutt A F B, NE 68113-1043 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2005 |
Last Update Date | 08/07/2007 |