Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 77989 | CA |
NPI | 1073087847 |
---|---|
Provider Name | Mrs. Christine Bustamante |
First Address | Pomona, CA 91766-7015 |
Second Address | Pomona, CA 91766-7015 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2019 |
Last Update Date | 15/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
77989 | (05) | CA |