Healthcare Provider Details

I. General information

NPI: 1972108850
Provider Name (Legal Business Name): GUADALUPE MUNOZ RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GUADALUPE IYOTTE RDA

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 ABBOTT ST APT 3
POMONA CA
91767-1454
US

IV. Provider business mailing address

3103 ABBOTT ST APT 3
POMONA CA
91767-1454
US

V. Phone/Fax

Practice location:
  • Phone: 909-729-8309
  • Fax:
Mailing address:
  • Phone: 909-729-8309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number74252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: