Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RAD3155 | ME |
NPI | 1144586892 |
---|---|
Provider Name | Sandra J Kimball |
First Address | Patten, ME 04765-0500 |
Second Address | Millinocket, ME 04462-1400 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2012 |
Last Update Date | 06/04/2012 |