=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205398567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAKANDRYIA PETERS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2019
-----------------------------------------------------
Last Update Date | 12/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2019 N RIVERSIDE AVE # C
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92377-4657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-877-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1909 S ISABELLA AVE
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-847-1054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 105229
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------