Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2003002706 | MO |
NPI | 1003874066 |
---|---|
Provider Name | Ms. Carla Daugherty |
First Address | St Louis, MO 63112-4265 |
Second Address | St Louis, MO 63112-4265 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2006 |
Last Update Date | 04/02/2013 |