Healthcare Provider Details

I. General information

NPI: 1063895712
Provider Name (Legal Business Name): CHRISTINA DORANTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10982 WEYBRIDGE DR
RANCHO CUCAMONGA CA
91730-6837
US

IV. Provider business mailing address

10982 WEYBRIDGE DR
RANCHO CUCAMONGA CA
91730-6837
US

V. Phone/Fax

Practice location:
  • Phone: 626-324-7664
  • Fax:
Mailing address:
  • Phone: 626-324-7664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number79011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: