Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 39958 | CA |
NPI | 1124342654 |
---|---|
Provider Name | Sally Landis |
First Address | San Rafael, CA 94901-5716 |
Second Address | San Rafael, CA 94901-5716 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2010 |
Last Update Date | 26/03/2010 |