Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 43595 | CA |
NPI | 1033401708 |
---|---|
Provider Name | Marjorie Domingo |
First Address | Garden Valley, CA 95633 |
Second Address | Garden Valley, CA 95633-9745 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2011 |
Last Update Date | 12/05/2011 |