=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760961403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERGIO RAMIREZ JR. RDA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2018
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5162 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-510-5920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 ECHANDIA ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-658-9935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 87080
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------