Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | OR |
NPI | 1356708523 |
---|---|
Provider Name | Mrs. Stacy Wood |
First Address | Canby, OR 97013-3455 |
Second Address | Oregon City, OR 97045-1067 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2016 |
Last Update Date | 19/01/2016 |