Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 45530 | CA |
NPI | 1003953563 |
---|---|
Provider Name | Thai Thuy Ta |
First Address | West Covina, CA 91790-2719 |
Second Address | West Covina, CA 91790-2719 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
445530 | G.G. DELTA (01) | CA |