Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 45078 | CA |
NPI | 1366689218 |
---|---|
Provider Name | Luis Telleria |
First Address | Los Angeles, CA 90033 |
Second Address | Los Angeles, CA 90022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2009 |
Last Update Date | 14/01/2009 |