Healthcare Provider Details

I. General information

NPI: 1962879684
Provider Name (Legal Business Name): ANTONIA VALENCIA RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E COLUMBIA ST SUITE 32
LONG BEACH CA
90806-1620
US

IV. Provider business mailing address

455 E COLUMBIA ST SUITE 32
LONG BEACH CA
90806-1620
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-3141
  • Fax: 562-933-2049
Mailing address:
  • Phone: 562-933-3141
  • Fax: 562-933-2049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number56051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: