MEDICARE: GRICELDA PERALTA R.D.H, R.D.H.A.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	296	CA
2	124Q00000X	Dental Hygienist	18576	CA

General Provider Information

NPI Number	:	1124349311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRICELDA PERALTA R.D.H, R.D.H.A.P.

Provider Business Mailing Address
First Line	:	322 CULVER BLVD
Second Line	:	SUITE 187
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7704
Country	:	US
Telephone Number	:	310-779-9712
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 CULVER BLVD
Second Line	:	SUITE 187
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7704
Country	:	US
Telephone Number	:	310-779-9712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2010
Last Update Date	:	06/22/2010

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