Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA87853 | CA |
NPI | 1164948311 |
---|---|
Provider Name | Marielena Borrayo |
First Address | San Jose, CA 95119-1847 |
Second Address | San Jose, CA 95119-1847 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2017 |
Last Update Date | 18/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDA87853 | (05) | CA |