Provider Demographics
NPI:1225354962
Name:MOLINA, CARLOS GUSTAVO (DENTAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:GUSTAVO
Last Name:MOLINA
Suffix:
Gender:M
Credentials:DENTAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 N HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3626
Mailing Address - Country:US
Mailing Address - Phone:213-858-2137
Mailing Address - Fax:
Practice Address - Street 1:148 N HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3626
Practice Address - Country:US
Practice Address - Phone:213-858-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant