Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN 17244 | FL |
NPI | 1578677290 |
---|---|
Provider Name | Teresa Johns |
First Address | Maitland, FL 32751 |
Second Address | Casselberry, FL 32707-5764 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DN17244 | LICENSE NUMBER (01) | FL |