Healthcare Provider Details

I. General information

NPI: 1205073269
Provider Name (Legal Business Name): MRS. BLANCA CAMPUZANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 S VERMONT AVE STE F
LOS ANGELES CA
90007-2298
US

IV. Provider business mailing address

119 N TOLAND AVE
WEST COVINA CA
91790-2352
US

V. Phone/Fax

Practice location:
  • Phone: 323-731-3333
  • Fax:
Mailing address:
  • Phone: 626-533-3027
  • 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: