Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2902006819 | MI |
NPI | 1023417805 |
---|---|
Provider Name | Grace Marie Montano-Sandoval |
First Address | Troy, MI 48083-6812 |
Second Address | Troy, MI 48083-6812 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2014 |
Last Update Date | 18/08/2014 |