Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 12716 | TX |
NPI | 1033415930 |
---|---|
Provider Name | Sandra Dee Wilson |
First Address | Conroe, TX 77301-2740 |
Second Address | Conroe, TX 77301-2740 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2011 |
Last Update Date | 10/02/2011 |