=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396377834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAGALY KETRON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W AMERICAN CANYON RD STE M8
-----------------------------------------------------
City | AMERICAN CANYON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94503-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-557-9080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 BEECHWOOD DR
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 105070
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------