Healthcare Provider Details

I. General information

NPI: 1518533033
Provider Name (Legal Business Name): CITLALI VANESSA SANTOS RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 W LINCOLN AVE
ANAHEIM CA
92801-6730
US

IV. Provider business mailing address

1814 W LINCOLN AVE
ANAHEIM CA
92801-6730
US

V. Phone/Fax

Practice location:
  • Phone: 714-805-7719
  • Fax:
Mailing address:
  • Phone: 714-805-7719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number84766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: