Provider Demographics
NPI:1003052796
Name:SANTIAGO, MARIA IRENE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:IRENE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 EL SELINDA AVE
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-3109
Mailing Address - Country:US
Mailing Address - Phone:323-560-1636
Mailing Address - Fax:
Practice Address - Street 1:1423 E GAGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1771
Practice Address - Country:US
Practice Address - Phone:323-983-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44094126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant