Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA87377 | CA |
NPI | 1194212621 |
---|---|
Provider Name | Josannie Veronica Ford |
First Address | Loma Linda, CA 92354-3144 |
Second Address | Loma Linda, CA 92354-3144 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2018 |
Last Update Date | 19/04/2018 |