Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 41093 | CA |
NPI | 1134411523 |
---|---|
Provider Name | Dr. Michelle Ikoma |
First Address | Los Angeles, CA 90056-1637 |
Second Address | Los Angeles, CA 90089-0641 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2011 |
Last Update Date | 04/05/2011 |