Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 63557 | CA |
NPI | 1144749508 |
---|---|
Provider Name | Dr. Jenna Benko |
First Address | Los Angeles, CA 90025-4414 |
Second Address | Los Angeles, CA 90025 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2017 |
Last Update Date | 04/06/2018 |