Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1053923540 |
---|---|
Provider Name | Mr. Randy Raymundo Penoliar |
First Address | North Hills, CA 91343-2234 |
Second Address | North Hills, CA 91343-2234 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2020 |
Last Update Date | 18/08/2020 |