Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223D0001X | Dental Public Health | DL13282 | MA |
Y | 1223D0001X | Dental Public Health | DL13672 | MA |
NPI | 1093237497 |
---|---|
Provider Name | Thalita Andenmatten |
First Address | Billerica, MA 01821-1431 |
Second Address | Roxbury, MA 02120-3432 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2017 |
Last Update Date | 06/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1093237497 | (05) | MA |