MEDICARE: MRS. GEMMA ATIGA AGUSTINES RDH

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	RDH13266	CA

General Provider Information

NPI Number	:	1134474596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GEMMA ATIGA AGUSTINES RDH

Provider Business Mailing Address
First Line	:	11430 VIA LIDO
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354
Country	:	UM
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7154 MAGNOLIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-3804
Country	:	US
Telephone Number	:	951-686-3666
Fax Number	:

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

Provider Enumeration Date	:	07/20/2012
Last Update Date	:	07/20/2012

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