Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 53502 | CA |
NPI | 1194155572 |
---|---|
Provider Name | Saul Rodriguez |
First Address | Glendale, CA 91205 |
Second Address | Glendale, CA 91205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2013 |
Last Update Date | 20/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDA 53502 | DENTAL PROVIDER (01) | CA |