Healthcare Provider Details

I. General information

NPI: 1902381452
Provider Name (Legal Business Name): SUSANA MAGANA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSANA SILAS RDH

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S ATLANTIC BLVD
LOS ANGELES CA
90022-2621
US

IV. Provider business mailing address

1056 BELMONT AVE APT 202
LONG BEACH CA
90804-5937
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-9191
  • Fax: 323-268-9119
Mailing address:
  • Phone: 562-279-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number27501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: