Healthcare Provider Details

I. General information

NPI: 1497226344
Provider Name (Legal Business Name): PRIMER IGNACIO BAYANI USITA RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11635 E. SOUTH STREET
ARTESIA CA
90701
US

IV. Provider business mailing address

11635 SOUTH ST
ARTESIA CA
90701-6628
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 562-924-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number63792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: