Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 15919 | CA |
NPI | 1174760789 |
---|---|
Provider Name | Grace Campos |
First Address | Los Angeles, CA 90033-2403 |
Second Address | Los Angeles, CA 90033-2403 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2009 |
Last Update Date | 20/01/2009 |