Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 44555 | CA |
NPI | 1356588966 |
---|---|
Provider Name | Mr. Miguel Angel Reyes |
First Address | South Gate, CA 90280-6546 |
Second Address | South Gate, CA 90280-6546 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2009 |
Last Update Date | 20/01/2009 |