Healthcare Provider Details

I. General information

NPI: 1366715062
Provider Name (Legal Business Name): RUBEN HURTADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2012
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15655 HAWTHORNE BLVD STE. A
LAWNDALE CA
90260-2665
US

IV. Provider business mailing address

15655 HAWTHORNE BLVD STE. A
LAWNDALE CA
90260-2665
US

V. Phone/Fax

Practice location:
  • Phone: 424-297-0513
  • Fax:
Mailing address:
  • Phone: 424-297-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: