Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H4891 | OR |
NPI | 1063958924 |
---|---|
Provider Name | Ms. Amy Tripp |
First Address | Grants Pass, OR 97526-1257 |
Second Address | Grants Pass, OR 97526-1257 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2017 |
Last Update Date | 16/01/2017 |