Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 126800000X | Dental Assistant |
NPI | 1124540406 |
---|---|
Provider Name | Mrs. Keyah Eubanks |
First Address | Hesperia, CA 92344 |
Second Address | Hesperia, CA 92344-5528 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2017 |
Last Update Date | 09/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000 | (05) | CA |