Healthcare Provider Details

I. General information

NPI: 1396377834
Provider Name (Legal Business Name): MAGALY KETRON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W AMERICAN CANYON RD STE M8
AMERICAN CANYON CA
94503-1181
US

IV. Provider business mailing address

1512 BEECHWOOD DR
MARTINEZ CA
94553-5304
US

V. Phone/Fax

Practice location:
  • Phone: 707-557-9080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105070
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: