MEDICARE: ERENE ATTALLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	DDS101059	CA

General Provider Information

NPI Number	:	1891154282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERENE ATTALLA

Provider Business Mailing Address
First Line	:	926 LATIGO LN
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-5898
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	36068 HIDDEN SPRINGS RD
Second Line	:	STE H
City	:	WILDOMAR
State	:	CA
Zip	:	92595-7679
Country	:	US
Telephone Number	:	951-579-4065
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2016
Last Update Date	:	02/15/2017

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Directions to “ ERENE ATTALLA ” Practice Location

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