Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 0402206328 | VA |
NPI | 1033888201 |
---|---|
Provider Name | Mrs. Emilie Bonovitch Ellis |
First Address | Chesterfield, VA 23832-2133 |
Second Address | Manakin Sabot, VA 23103-2250 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2021 |
Last Update Date | 10/09/2021 |