Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 28984 | CA |
NPI | 1043686975 |
---|---|
Provider Name | Conrad Ignatius Harmon SR. |
First Address | Los Angeles, CA 90043-1321 |
Second Address | Los Angeles, CA 90043-1321 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2015 |
Last Update Date | 14/08/2015 |