Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH3212 | NM |
NPI | 1053807149 |
---|---|
Provider Name | Gina Moraga |
First Address | Albuquerque, NM 87110-3935 |
Second Address | Albuquerque, NM 87110-3935 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2018 |
Last Update Date | 02/07/2018 |