Healthcare Provider Details

I. General information

NPI: 1851788004
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 E 12TH ST
OAKLAND CA
94601-3463
US

IV. Provider business mailing address

1040 84TH AVE
OAKLAND CA
94621-1832
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-3301
  • Fax:
Mailing address:
  • Phone: 510-325-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number28770
License Number StateCA

VIII. Authorized Official

Name: TERESITA MEJIA
Title or Position: SITE MANAGER
Credential: MBA
Phone: 510-535-3301