Healthcare Provider Details

I. General information

NPI: 1013154103
Provider Name (Legal Business Name): EVIE VIVALDO-HERNANDEZ RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5807 N FIGUEROA ST
LOS ANGELES CA
90042-4227
US

IV. Provider business mailing address

5807 N FIGUEROA ST
LOS ANGELES CA
90042-4227
US

V. Phone/Fax

Practice location:
  • Phone: 323-982-0999
  • Fax: 323-982-0333
Mailing address:
  • Phone: 323-982-0999
  • Fax: 323-982-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number63818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: