Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | CA |
NPI | 1104052687 |
---|---|
Provider Name | Jessica Diaz |
First Address | Van Nuys, CA 91405 |
Second Address | Van Nuys, CA 91405-2626 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2009 |
Last Update Date | 10/06/2009 |