Healthcare Provider Details

I. General information

NPI: 1306233903
Provider Name (Legal Business Name): JULIO MADRID RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JULIO STEPHEN MADRID RDA

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16205 SEVILLE AVE
FONTANA CA
92335-3383
US

IV. Provider business mailing address

16205 SEVILLE AVE
FONTANA CA
92335-3383
US

V. Phone/Fax

Practice location:
  • Phone: 909-997-3373
  • Fax:
Mailing address:
  • Phone: 909-997-3373
  • 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: