Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1093256497 |
---|---|
Provider Name | Jerry V Iloreta |
First Address | Tripler Amc, HI 96859-5001 |
Second Address | Tripler Amc, HI 96859-5001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2017 |
Last Update Date | 17/03/2017 |