Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DPH000004 | GA |
NPI | 1013090307 |
---|---|
Provider Name | Olivia Taylor |
First Address | Rome, GA 30165-1345 |
Second Address | Rome, GA 30165-1345 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 08/07/2007 |