Healthcare Provider Details

I. General information

NPI: 1962640144
Provider Name (Legal Business Name): ARIEL CISNEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21229 HAWTHORNE BLVD
TORRANCE CA
90503-5501
US

IV. Provider business mailing address

623 MAR VISTA AVE
WILMINGTON CA
90744-4940
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-5600
  • Fax: 310-792-5628
Mailing address:
  • Phone: 310-549-1826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: