Healthcare Provider Details

I. General information

NPI: 1861038713
Provider Name (Legal Business Name): ISAIAH DARIAN VASQUEZ RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9910 LONG BEACH BLVD STE A
LYNWOOD CA
90262-1561
US

IV. Provider business mailing address

8020 BIRCHCREST RD APT E104
DOWNEY CA
90240-2107
US

V. Phone/Fax

Practice location:
  • Phone: 323-538-2002
  • Fax:
Mailing address:
  • Phone: 562-565-7479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number93763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: