Healthcare Provider Details

I. General information

NPI: 1861039893
Provider Name (Legal Business Name): ANGELINA IMBAT DELA CRUZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELINA DELACRUZ SONGCO RDH

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 520448 BASILONE RD
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

141 BRISAS ST
OCEANSIDE CA
92058-7967
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7455
  • Fax:
Mailing address:
  • Phone: 760-212-5707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number31873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: