Healthcare Provider Details

I. General information

NPI: 1437400264
Provider Name (Legal Business Name): MS. EDELYN MAE FELISARIO COLONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 LA SIERRA AVE SUITE 108
RIVERSIDE CA
92503-5271
US

IV. Provider business mailing address

3380 LA SIERRA AVE., SUITE 108
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 951-354-9999
  • Fax: 951-354-6666
Mailing address:
  • Phone: 951-354-9999
  • Fax: 951-354-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: