Healthcare Provider Details

I. General information

NPI: 1457897068
Provider Name (Legal Business Name): MAURO MIRAMONTES III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 LA SIERRA AVE
RIVERSIDE CA
92503-5271
US

IV. Provider business mailing address

66031 1ST ST
DESERT HOT SPRINGS CA
92240-3636
US

V. Phone/Fax

Practice location:
  • Phone: 951-354-9999
  • Fax:
Mailing address:
  • Phone: 760-620-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number79237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: