Healthcare Provider Details

I. General information

NPI: 1073700530
Provider Name (Legal Business Name): MARIA RAYE GONZALES OLIVEROS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E CARSON ST
CARSON CA
90745-2720
US

IV. Provider business mailing address

625 E CARSON ST
CARSON CA
90745-2720
US

V. Phone/Fax

Practice location:
  • Phone: 310-830-5787
  • Fax: 310-830-3348
Mailing address:
  • Phone: 310-830-5787
  • Fax: 310-830-3348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: