Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 44849 | CA |
NPI | 1063034734 |
---|---|
Provider Name | Gina Costa |
First Address | Anaheim, CA 92812-7083 |
Second Address | Pomona, CA 91766-7015 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2020 |
Last Update Date | 15/05/2020 |