Healthcare Provider Details

I. General information

NPI: 1699252759
Provider Name (Legal Business Name): ROSA M PARRA RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSA M GUTIERREZ RDA

II. Dates (important events)

Enumeration Date: 07/22/2018
Last Update Date: 07/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

IV. Provider business mailing address

20508 ARLINE AVE
LAKEWOOD CA
90715-1424
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax: 310-820-0588
Mailing address:
  • Phone: 562-441-2634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number60761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: