Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 91192 | CA |
NPI | 1356922363 |
---|---|
Provider Name | Liduvina Lopez |
First Address | South Gate, CA 90280-4229 |
Second Address | South Gate, CA 90280-4229 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2021 |
Last Update Date | 20/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
91192 | (05) | CA |