Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 87646 | CA |
NPI | 1114404779 |
---|---|
Provider Name | Jacob Garza |
First Address | Moreno Valley, CA 92557-7749 |
Second Address | Riverside, CA 92503-5225 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2018 |
Last Update Date | 25/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NA | NA (01) |