Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | CA |
NPI | 1104119924 |
---|---|
Provider Name | Jose Rodriguez |
First Address | Riverside, CA 92505-3003 |
Second Address | Riverside, CA 92503-5271 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2011 |
Last Update Date | 26/05/2011 |