Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1083187967 |
---|---|
Provider Name | Rose Booth |
First Address | Clackamas, OR 97015-9782 |
Second Address | Clackamas, OR 97015-9782 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2019 |
Last Update Date | 03/01/2019 |