Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 9106 | MN |
NPI | 1154855666 |
---|---|
Provider Name | Mrs. Michelle O'connell |
First Address | Woodbury, MN 55125-4883 |
Second Address | Woodbury, MN 55125-4883 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2017 |
Last Update Date | 12/04/2017 |