Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1306233903 |
---|---|
Provider Name | Julio Madrid |
First Address | Fontana, CA 92335-3383 |
Second Address | Fontana, CA 92335-3383 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2015 |
Last Update Date | 21/04/2015 |