Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1144671652 |
---|---|
Provider Name | Mr. Mark Kekoa Valdez |
First Address | Apo, AA 76544 |
Second Address | Fort Hood, TX 76544 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2016 |
Last Update Date | 27/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H01098950 | DENTAL HYGIENIST (01) | HI |