Healthcare Provider Details

I. General information

NPI: 1942975735
Provider Name (Legal Business Name): ALEX IVAN RUBIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 S ALAMEDA ST STE 101
COMPTON CA
90220-4976
US

IV. Provider business mailing address

15716 S LORELLA AVE
GARDENA CA
90248-2529
US

V. Phone/Fax

Practice location:
  • Phone: 310-627-5600
  • Fax:
Mailing address:
  • Phone: 310-627-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: