Healthcare Provider Details

I. General information

NPI: 1760900914
Provider Name (Legal Business Name): MAURICIO PINEDA RDA III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 WHITTIER BLVD
PICO RIVERA CA
90660-2410
US

IV. Provider business mailing address

6007 3/4 TEMPLE CITY BLVD
TEMPLE CITY CA
91780-2013
US

V. Phone/Fax

Practice location:
  • Phone: 562-456-1111
  • Fax:
Mailing address:
  • Phone: 562-704-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA86217
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRDA86217
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: