Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1164055125 |
---|---|
Provider Name | Tracey King |
First Address | Lynwood, CA 90262-5233 |
Second Address | Lynwood, CA 90262-5233 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/02/2020 |
Last Update Date | 18/02/2020 |