Healthcare Provider Details

I. General information

NPI: 1215182613
Provider Name (Legal Business Name): SHELLI BLAKE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3242 W 8TH ST
LOS ANGELES CA
90005-2176
US

IV. Provider business mailing address

3242 W. 8TH STREET QUEENSCARE FAMILY CLINICS
LOS ANGELES CA
90005
US

V. Phone/Fax

Practice location:
  • Phone: 213-368-9779
  • Fax:
Mailing address:
  • Phone: 213-368-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number14938
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: