Healthcare Provider Details

I. General information

NPI: 1992350359
Provider Name (Legal Business Name): CARLA DENISE CANNON RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14030 CHADRON AVE APT 219
HAWTHORNE CA
90250-8247
US

IV. Provider business mailing address

14030 CHADRON AVE APT 219
HAWTHORNE CA
90250-8247
US

V. Phone/Fax

Practice location:
  • Phone: 424-789-4665
  • Fax:
Mailing address:
  • Phone: 424-789-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number38996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: