Healthcare Provider Details

I. General information

NPI: 1407225907
Provider Name (Legal Business Name): FLORIE VANESSA MANCILLA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 CHAPMAN AVE #200
GARDEN GROVE CA
92840-4700
US

IV. Provider business mailing address

10602 CHAPMAN AVE #200
GARDEN GROVE CA
92840-4700
US

V. Phone/Fax

Practice location:
  • Phone: 714-638-5990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number26181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: