Healthcare Provider Details

I. General information

NPI: 1134408560
Provider Name (Legal Business Name): MYLENE PALENCIA FERNAN RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12730 HAWTHORNE BLVD SUITE D
HAWTHORNE CA
90250-3919
US

IV. Provider business mailing address

1014 COTA AVE APT 3
TORRANCE CA
90501-2166
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4000
  • Fax:
Mailing address:
  • Phone: 310-291-8414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number38102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: