Provider Demographics
NPI:1033277215
Name:AGRA, ANTONIO FANDINO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:FANDINO
Last Name:AGRA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17613 PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701
Mailing Address - Country:US
Mailing Address - Phone:562-809-8482
Mailing Address - Fax:562-402-4012
Practice Address - Street 1:17613 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701
Practice Address - Country:US
Practice Address - Phone:562-809-8482
Practice Address - Fax:562-402-4012
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25664122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA501908OtherMEDICAL