Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1255781787 |
---|---|
Provider Name | Ms. Blanca Estela Diaz |
First Address | Fort Campbell, KY 42223 |
Second Address | Fort Carson, CO 80913-4095 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2016 |
Last Update Date | 22/05/2017 |