Healthcare Provider Details

I. General information

NPI: 1003052796
Provider Name (Legal Business Name): MARIA IRENE SANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E GAGE AVE SUITE A
LOS ANGELES CA
90001-1771
US

IV. Provider business mailing address

6601 EL SELINDA AVE
BELL GARDENS CA
90201-3109
US

V. Phone/Fax

Practice location:
  • Phone: 323-983-4000
  • Fax:
Mailing address:
  • Phone: 323-560-1636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number44094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: