Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1023680592 |
---|---|
Provider Name | Ricky Snipes |
First Address | Fort Campbell, KY 42223-5582 |
Second Address | Fort Campbell, KY 42223-5582 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2021 |
Last Update Date | 14/07/2021 |