Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 82300 | CA |
NPI | 1336703990 |
---|---|
Provider Name | Lance Anthony White |
First Address | Imperial Beach, CA 91932-3709 |
Second Address | Imperial Beach, CA 91932-3709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2019 |
Last Update Date | 29/04/2019 |