Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 007527 | PR |
NPI | 1043736218 |
---|---|
Provider Name | Modomi J. Roman Lebron |
First Address | Patillas, PR 00723 |
Second Address | Patillas, PR 00723-0072 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
196237 | REGISTRY CERTIFICATE (01) | PR |