Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 72577 | CA |
NPI | 1376906974 |
---|---|
Provider Name | Willy Villagran |
First Address | Anaheim, CA 92805-4129 |
Second Address | Torrance, CA 90503-5501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2016 |
Last Update Date | 05/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
72577 | (05) | CA |