Provider Demographics
NPI:1174864003
Name:AVILA, RITA HERRERA
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:HERRERA
Last Name:AVILA
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 1:1925 CONTESSA
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:179 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7716
Practice Address - Country:US
Practice Address - Phone:714-288-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27293124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist