Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | DN13505 | GA |
N | 213EG0000X | General Practice | DN13505 | GA |
Y | 1223P0700X | Prosthodontist | DN13505 | GA |
NPI | 1184875882 |
---|---|
Provider Name | Ms. Syretta Wells |
First Address | Forest Park, GA 30297-6101 |
Second Address | Forest Park, GA 30297-6101 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2008 |
Last Update Date | 01/10/2008 |