Healthcare Provider Details

I. General information

NPI: 1235493057
Provider Name (Legal Business Name): GUADALUPE MARIA MAGANA RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GUADALUPE MARIA BANUELOS RDA

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14525 LAKEWOOD BLVD SUITE A
PARAMOUNT CA
90723-3638
US

IV. Provider business mailing address

11229 KLINGERMAN ST APT 3
EL MONTE CA
91733-2826
US

V. Phone/Fax

Practice location:
  • Phone: 562-272-0000
  • Fax:
Mailing address:
  • Phone: 951-662-2316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA69102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: