Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 75440 | CA |
NPI | 1295399004 |
---|---|
Provider Name | Annie Dang |
First Address | Covina, CA 91724-2522 |
Second Address | Baldwin Park, CA 91706-3163 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2019 |
Last Update Date | 26/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
75440 | (05) | CA |