Healthcare Provider Details

I. General information

NPI: 1912554072
Provider Name (Legal Business Name): BRENDA ALEJANDRA RECINOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
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

7210 DAY CREEK BLVD STE 1207210
RANCHO CUCAMONGA CA
91739-7537
US

V. Phone/Fax

Practice location:
  • Phone: 909-667-2550
  • Fax:
Mailing address:
  • Phone: 909-667-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number93385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: