Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1215296595 |
---|---|
Provider Name | Ms. Bethany Carmela Johnson |
First Address | Salem, OR 97305-1223 |
Second Address | Salem, OR 97305-1223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2012 |
Last Update Date | 08/05/2012 |