Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 3022 | OK |
NPI | 1053681346 |
---|---|
Provider Name | Mrs. Misty Smith |
First Address | Wewoka, OK 74884 |
Second Address | Wewoka, OK 74884 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2012 |
Last Update Date | 04/01/2012 |