Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1104420223 |
---|---|
Provider Name | Rebecca Renee White |
First Address | Fort Carson, CO 80913-4603 |
Second Address | Fort Carson, CO 80913-4603 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2020 |
Last Update Date | 30/11/2020 |