Healthcare Provider Details

I. General information

NPI: 1134474596
Provider Name (Legal Business Name): GEMMA ATIGA AGUSTINES RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7154 MAGNOLIA AVE
RIVERSIDE CA
92504-3804
US

IV. Provider business mailing address

11430 VIA LIDO
LOMA LINDA CA
92354
UM

V. Phone/Fax

Practice location:
  • Phone: 951-686-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH13266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: