Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 57746 | CA |
NPI | 1063664621 |
---|---|
Provider Name | Wendy Christina Gregorius |
First Address | Loma Linda, CA 92350-0001 |
Second Address | Loma Linda, CA 92350-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2008 |
Last Update Date | 15/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
57746 | STATE LICENSE (01) | CA |