Healthcare Provider Details

I. General information

NPI: 1861090334
Provider Name (Legal Business Name): KHARA TENISE TAYLOR RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 DAY CREEK BLVD STE 110
RANCHO CUCAMONGA CA
91739-7543
US

IV. Provider business mailing address

180 E JARVIS ST APT 705
PERRIS CA
92571-2913
US

V. Phone/Fax

Practice location:
  • Phone: 909-803-1111
  • Fax:
Mailing address:
  • Phone: 951-229-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA90270
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: