Provider Demographics
NPI:1114164290
Name:RICO, SONIA
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:RICO
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 1:3373 LIBERTY BLVD
Mailing Address - Street 2:APT # C
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2368
Mailing Address - Country:US
Mailing Address - Phone:323-712-1615
Mailing Address - Fax:
Practice Address - Street 1:3373 LIBERTY BLVD
Practice Address - Street 2:APT # C
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2368
Practice Address - Country:US
Practice Address - Phone:323-712-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64530126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant