Healthcare Provider Details

I. General information

NPI: 1124349311
Provider Name (Legal Business Name): GRICELDA PERALTA R.D.H, R.D.H.A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 CULVER BLVD SUITE 187
PLAYA DEL REY CA
90293-7704
US

IV. Provider business mailing address

322 CULVER BLVD SUITE 187
PLAYA DEL REY CA
90293-7704
US

V. Phone/Fax

Practice location:
  • Phone: 310-779-9712
  • Fax:
Mailing address:
  • Phone: 310-779-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number296
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number18576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: