Healthcare Provider Details

I. General information

NPI: 1518380849
Provider Name (Legal Business Name): CARLOS MARIN RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 CHAPMAN AVE SUITE 200
GARDEN GROVE CA
92840-3146
US

IV. Provider business mailing address

10602 CHAPMAN AVE SUITE
GARDEN GROVE CA
92840-3146
US

V. Phone/Fax

Practice location:
  • Phone: 714-638-5990
  • Fax: 714-638-5992
Mailing address:
  • Phone: 714-638-5990
  • Fax: 714-638-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number66429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: