Healthcare Provider Details

I. General information

NPI: 1053923540
Provider Name (Legal Business Name): RANDY RAYMUNDO PENOLIAR RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15350 NORDHOFF ST UNIT A15350
NORTH HILLS CA
91343-2234
US

IV. Provider business mailing address

15350 NORDHOFF ST UNIT A15350
NORTH HILLS CA
91343-2234
US

V. Phone/Fax

Practice location:
  • Phone: 818-724-8416
  • Fax:
Mailing address:
  • Phone: 818-724-8416
  • 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: