Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 1759 | PR |
NPI | 1134228349 |
---|---|
Provider Name | Beatriz Elena Ibanez |
First Address | San German, PR 00683-0188 |
Second Address | San German, PR 00683-0188 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1759 | LICENSE NUMBER (01) | PR |