Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 69704 | CA |
NPI | 1235377219 |
---|---|
Provider Name | Mrs. Kesia Nichole Davis Eaglin |
First Address | Riverside, CA 92507-5710 |
Second Address | Riverside, CA 92507-5710 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2009 |
Last Update Date | 28/01/2009 |