Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 689557 | CA |
NPI | 1275914863 |
---|---|
Provider Name | Lisette Olivia Alonzo |
First Address | Downey, CA 90241-4793 |
Second Address | Los Angeles, CA 90007-2298 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2015 |
Last Update Date | 09/06/2015 |