Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1295152262 |
---|---|
Provider Name | Mrs. Cheryl Marie Wildman |
First Address | Lawton, OK 73501-8399 |
Second Address | Ft Sill, OK 73503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2014 |
Last Update Date | 27/03/2014 |