Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 33289 | CA |
NPI | 1285004937 |
---|---|
Provider Name | Elena Grin |
First Address | Torrance, CA 90503-4496 |
Second Address | Torrance, CA 90503-4496 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2015 |
Last Update Date | 06/10/2015 |