Healthcare Provider Details

I. General information

NPI: 1467877191
Provider Name (Legal Business Name): MAYRA POOL RDHAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10866 BLUFFSIDE DR 3
STUDIO CITY CA
91604-3343
US

IV. Provider business mailing address

10866 BLUFFSIDE DR 3
STUDIO CITY CA
91604-3343
US

V. Phone/Fax

Practice location:
  • Phone: 213-948-4425
  • Fax:
Mailing address:
  • Phone: 213-948-4425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: