Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 22DI02487800 | NJ |
N | 1223P0221X | Pediatric Dentist | 27861 | TX |
NPI | 1063709830 |
---|---|
Provider Name | Dr. Fanny Kamwa Agnero |
First Address | Rio Grande City, TX 78582-9433 |
Second Address | Rio Grande City, TX 78582-9433 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2011 |
Last Update Date | 29/04/2021 |