Healthcare Provider Details

I. General information

NPI: 1376112946
Provider Name (Legal Business Name): CHARLINE JOSEPHINE CERVELLERA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 W POPLAR AVE
PORTERVILLE CA
93257-5839
US

IV. Provider business mailing address

9 HAWTHORNE PL APT 15F
BOSTON MA
02114-2330
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 424-535-6297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number108382
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL14790
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: