Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA92366 | CA |
NPI | 1124633292 |
---|---|
Provider Name | Mario A Cruz |
First Address | South Gate, CA 90280-2612 |
Second Address | South Gate, CA 90280-2612 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2020 |
Last Update Date | 15/09/2020 |