Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 82517 | CA |
NPI | 1295322634 |
---|---|
Provider Name | Anthony Urrea |
First Address | West Covina, CA 91790-1359 |
Second Address | West Covina, CA 91790-1359 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2020 |
Last Update Date | 30/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDA82517 | (05) | CA |