Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 61630 | CA |
NPI | 1053791046 |
---|---|
Provider Name | Diane Costandi |
First Address | Seal Beach, CA 90740-5368 |
Second Address | Seal Beach, CA 90740-5368 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2015 |
Last Update Date | 04/06/2015 |