Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H007694 | AZ |
NPI | 1043963358 |
---|---|
Provider Name | Patricia Baca |
First Address | Surprise, AZ 85374-4580 |
Second Address | Surprise, AZ 85374-4580 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2022 |
Last Update Date | 27/01/2022 |