Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA92155 | CA |
NPI | 1043879711 |
---|---|
Provider Name | Rosa Maria Pelayo Barraza |
First Address | Hemet, CA 92545-3617 |
Second Address | Hemet, CA 92545-3617 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2019 |
Last Update Date | 06/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
111 | (05) | CA |