Healthcare Provider Details

I. General information

NPI: 1790294627
Provider Name (Legal Business Name): RODOLFO CHAVEZ RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 09/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44558 10TH ST W
LANCASTER CA
93534-3333
US

IV. Provider business mailing address

628 E AVENUE J11
LANCASTER CA
93535-1231
US

V. Phone/Fax

Practice location:
  • Phone: 661-206-2424
  • Fax:
Mailing address:
  • Phone: 661-877-1791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number76623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: