Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA56326 | CA |
NPI | 1275078107 |
---|---|
Provider Name | Mitra Tahiree |
First Address | Murrieta, CA 92563-2737 |
Second Address | Murrieta, CA 92563-2737 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2017 |
Last Update Date | 02/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDA56326 | (05) | CA |