Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 51138 | CA |
NPI | 1144423278 |
---|---|
Provider Name | Tina Sun |
First Address | Monterey Park, CA 91754-5245 |
Second Address | City Of Industry, CA 91748-1370 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2007 |
Last Update Date | 08/07/2007 |