Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 73-01201 | CA |
NPI | 1245461797 |
---|---|
Provider Name | Martha Banuelos |
First Address | Palmdale, CA 93550-1309 |
Second Address | Palmdale, CA 93550-1309 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2009 |
Last Update Date | 31/07/2009 |