Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH010304 | GA |
N | 124Q00000X | Dental Hygienist | DH17953 | FL |
NPI | 1043766603 |
---|---|
Provider Name | Ms. Kimberly Martin |
First Address | Acworth, GA 30101-3792 |
Second Address | Atlanta, GA 30303-3030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 01/09/2016 |