Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 51046 | CA |
NPI | 1033245345 |
---|---|
Provider Name | Miss Maria Camila Borrero Fonseca |
First Address | Tracy, CA 95376-3084 |
Second Address | Tracy, CA 95376-3084 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2007 |
Last Update Date | 22/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
51046 | DENTAL LICENSE (01) | CA |