Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH003959 | GA |
NPI | 1013368562 |
---|---|
Provider Name | Sandra Thompson |
First Address | Fort Polk, LA 71459 |
Second Address | Fort Polk, LA 71459 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2016 |
Last Update Date | 27/06/2016 |