Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1063176311 |
---|---|
Provider Name | Carlos Medellin |
First Address | Houston, TX 77084-5262 |
Second Address | Houston, TX 77084-5262 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2021 |
Last Update Date | 23/10/2021 |