Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 102957 | CA |
NPI | 1629557152 |
---|---|
Provider Name | Jia Tian |
First Address | San Jose, CA 95123-1655 |
Second Address | San Jose, CA 95123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2018 |
Last Update Date | 23/07/2019 |