Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 124Q00000X | Dental Hygienist | ||
Y | 124Q00000X | Dental Hygienist | 2902004953 | MI |
NPI | 1053810291 |
---|---|
Provider Name | Diane Larosa |
First Address | Pontiac, MI 48340-2919 |
Second Address | Pontiac, MI 48340-2919 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2018 |
Last Update Date | 02/02/2018 |