Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH26009 | FL |
NPI | 1013672575 |
---|---|
Provider Name | Christopher Juffan Galeos Porquiado |
First Address | Camp Lejeune, NC 28542-0125 |
Second Address | Camp Lejeune, NC 28542-0125 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2021 |
Last Update Date | 01/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Y6208144 | TRICARE (01) | CA |