Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 008590 | CT |
NPI | 1023650215 |
---|---|
Provider Name | Daisy Mojica |
First Address | Stamford, CT 06902-2419 |
Second Address | Stamford, CT 06902-2419 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/10/2019 |
Last Update Date | 09/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008590 | DENTAL LICENSE (01) | CT |