Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1164914487 |
---|---|
Provider Name | Mrs. Mahin Rezamand |
First Address | San Bernardino, CA 92407-9008 |
Second Address | Montebello, CA 90640-2584 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2018 |
Last Update Date | 01/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NCF780A52374 | ANTHEM BLUE CROSS (01) |