Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 1491 | AZ |
NPI | 1003110065 |
---|---|
Provider Name | Ms. Debra Gordon |
First Address | Mesa, AZ 85208-0106 |
Second Address | Tempe, AZ 85283-3747 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2011 |
Last Update Date | 28/06/2011 |