Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 1579 | CA |
NPI | 1346834371 |
---|---|
Provider Name | Ricardo Ernesto Vaquerano |
First Address | Panorama City, CA 91402-6516 |
Second Address | Reseda, CA 91335-4475 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2021 |
Last Update Date | 20/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1579 | AEF (01) | CA |
22 | OA (01) | CA |
75121 | RDA (01) | CA |