Healthcare Provider Details

I. General information

NPI: 1689204885
Provider Name (Legal Business Name): MICHELLE MACIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 09/19/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 S VERMONT AVE
LOS ANGELES CA
90007-2298
US

IV. Provider business mailing address

765 WEYBURN PL APT 405
LOS ANGELES CA
90024-2877
US

V. Phone/Fax

Practice location:
  • Phone: 310-409-4277
  • Fax:
Mailing address:
  • Phone: 831-789-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number109464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: