Healthcare Provider Details

I. General information

NPI: 1225653488
Provider Name (Legal Business Name): MAYRA ALEJANDRA MACIAS RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2020
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

IV. Provider business mailing address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-3923
  • Fax:
Mailing address:
  • Phone: 714-598-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number90133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: