Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH3025 | NM |
NPI | 1063645455 |
---|---|
Provider Name | Elmer Eleazar Gonzalez |
First Address | Albuquerque, NM 87121-2611 |
Second Address | Albuquerque, NM 87102-1740 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2009 |
Last Update Date | 01/09/2009 |