Healthcare Provider Details

I. General information

NPI: 1164669784
Provider Name (Legal Business Name): ANA M TELLERIA DENTAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5162 E WHITTIER BLVD
LOS ANGELES CA
90022
US

IV. Provider business mailing address

420 N EVERGREEN AVE APT 224
LOS ANGELES CA
90033
US

V. Phone/Fax

Practice location:
  • Phone: 323-415-6161
  • Fax: 323-416-0675
Mailing address:
  • Phone: 323-495-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: