Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 31-014570 | OH |
NPI | 1053863969 |
---|---|
Provider Name | Mrs. Kim Bakos |
First Address | Elyria, OH 44035-5325 |
Second Address | Elyria, OH 44035-5325 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2016 |
Last Update Date | 26/10/2016 |