Healthcare Provider Details

I. General information

NPI: 1568163319
Provider Name (Legal Business Name): MINERVA LETICIA HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MAIN ST
SANTA ANA CA
92701-3576
US

IV. Provider business mailing address

3580 SUNNYSIDE DR
YORBA LINDA CA
92886-6919
US

V. Phone/Fax

Practice location:
  • Phone: 657-282-6355
  • Fax:
Mailing address:
  • Phone: 714-742-6812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: