Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 56779 | CA |
N | 1223D0004X | Dentist Anesthesiologist | 56779 | CA |
Y | 1223D0004X | Dentist Anesthesiologist | 5993 | NV |
NPI | 1700044781 |
---|---|
Provider Name | Amanda Jo Okundaye |
First Address | Las Vegas, NV 89147-8079 |
Second Address | Los Angeles, CA 90049-5043 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2008 |
Last Update Date | 20/05/2013 |