Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 4679 | TN |
N | 122300000X | Dentist | 5475 | DC |
NPI | 1003077108 |
---|---|
Provider Name | S Adele Doherty |
First Address | Mount Juliet, TN 37121-0646 |
Second Address | Goodlettsville, TN 37072-1545 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2008 |
Last Update Date | 20/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5870 | (05) | TN |