Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | HAP 537 | CA |
NPI | 1013307651 |
---|---|
Provider Name | Kevin Dizon |
First Address | San Jose, CA 95123 |
Second Address | San Jose, CA 95123 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2015 |
Last Update Date | 04/02/2015 |