Provider Demographics
NPI:1225653488
Name:MACIAS, MAYRA ALEJANDRA (RDA)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:ALEJANDRA
Last Name:MACIAS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 N TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7716
Mailing Address - Country:US
Mailing Address - Phone:714-598-3923
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:714-598-3923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90133126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90133Medicaid