Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1205172772 |
---|---|
Provider Name | Juan Lopez |
First Address | Los Angeles, CA 90017-1000 |
Second Address | Los Angeles, CA 90017-1000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2013 |
Last Update Date | 02/01/2013 |