Healthcare Provider Details

I. General information

NPI: 1033675350
Provider Name (Legal Business Name): MARIA DE LA LUZ CAMACHO RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 N LAKEWOOD BLVD
LONG BEACH CA
90808-1558
US

IV. Provider business mailing address

11212 FLALLON AVE
NORWALK CA
90650-1621
US

V. Phone/Fax

Practice location:
  • Phone: 562-420-1701
  • Fax:
Mailing address:
  • Phone: 562-277-5710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA90299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: