Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 46812 | CA |
NPI | 1003989427 |
---|---|
Provider Name | Maricel Guarin Fortin |
First Address | Glendale, CA 91205-1533 |
Second Address | Glendale, CA 91205-1533 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 08/07/2007 |