Healthcare Provider Details

I. General information

NPI: 1659725315
Provider Name (Legal Business Name): NATALY GRACIELA MAGANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 LA RICA AVE STE D
BALDWIN PARK CA
91706-3163
US

IV. Provider business mailing address

15093 KINGSFORD AVE
ADELANTO CA
92301-4802
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-9171
  • Fax:
Mailing address:
  • Phone: 760-713-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number73759
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: