Provider Demographics
NPI:1346834371
Name:VAQUERANO, RICARDO ERNESTO (RDAEF)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:ERNESTO
Last Name:VAQUERANO
Suffix:
Gender:M
Credentials:RDAEF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13982 STROUD ST
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-6516
Mailing Address - Country:US
Mailing Address - Phone:818-674-1954
Mailing Address - Fax:
Practice Address - Street 1:18308 SHERMAN WAY STE 1
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4475
Practice Address - Country:US
Practice Address - Phone:818-881-0404
Practice Address - Fax:818-881-7108
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1579126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22OtherOA
CA75121OtherRDA
CA1579OtherAEF