Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 124Q00000X | Dental Hygienist | 27562 | CA |
Y | 124Q00000X | Dental Hygienist | RDHAP 628 | CA |
NPI | 1073983250 |
---|---|
Provider Name | Jennifer Van |
First Address | Stanton, CA 90680 |
Second Address | Stanton, CA 90680 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2015 |
Last Update Date | 10/09/2016 |