Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1053769257 |
---|---|
Provider Name | Ms. Annette Marie Cordova |
First Address | Pueblo, CO 81008-2173 |
Second Address | Pueblo, CO 81008-2173 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2016 |
Last Update Date | 28/09/2017 |