Provider Demographics
NPI:1376002287
Name:LICEA, ERICA BERENICE (RDA ORTHO ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:BERENICE
Last Name:LICEA
Suffix:
Gender:F
Credentials:RDA ORTHO ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 W LA GLORIA DR
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4466
Mailing Address - Country:US
Mailing Address - Phone:951-465-9162
Mailing Address - Fax:
Practice Address - Street 1:1342 W LA GLORIA DR
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-4466
Practice Address - Country:US
Practice Address - Phone:951-465-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66604126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA66604Medicaid