Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 8255 | SC |
NPI | 1063960706 |
---|---|
Provider Name | Mrs. Tiesha Giselle Jenkins |
First Address | Florence, SC 29506-5127 |
Second Address | Columbia, SC 29207-6022 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2016 |
Last Update Date | 12/09/2016 |