Provider Demographics
NPI:1164906889
Name:SOLANO, EMMANUEL GABRIEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:GABRIEL
Last Name:SOLANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 S 4TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3522
Mailing Address - Country:US
Mailing Address - Phone:323-596-5481
Mailing Address - Fax:
Practice Address - Street 1:1705 S 4TH ST APT C
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3522
Practice Address - Country:US
Practice Address - Phone:323-596-5481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66928126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA66928Medicaid