Healthcare Provider Details

I. General information

NPI: 1780192823
Provider Name (Legal Business Name): MALY VILICHAY QUINTO RDH23328
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax: 619-445-1188
Mailing address:
  • Phone: 619-445-1188
  • Fax: 619-659-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH23328
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: