| NPI | 1467020362 |
|---|---|
| Former Name | KELSIE LYNN JACK |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 61874) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 61874) |
| Enumeration Date | 2021-06-16 |
| Last Update Date | 2025-03-27 |