Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 21385 | CA |
NPI | 1043702475 |
---|---|
Provider Name | Susan Bowles |
First Address | Redway, CA 95560-0769 |
Second Address | Redway, CA 95560-0769 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2018 |
Last Update Date | 01/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1235206087 | (05) | CA |