Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 73043 | CA |
NPI | 1235704503 |
---|---|
Provider Name | Lisa Allen Massey |
First Address | Rialto, CA 92376-2418 |
Second Address | Rialto, CA 92376-2418 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2021 |
Last Update Date | 20/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
73043 | REGISTERED DENTAL ASSISTANT (01) | CA |