Provider Demographics
NPI:1376084590
Name:SANTOS, MIREYA DEE (RDA)
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:DEE
Last Name:SANTOS
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 1:10721 TELECHRON AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-3421
Mailing Address - Country:US
Mailing Address - Phone:562-278-4950
Mailing Address - Fax:
Practice Address - Street 1:10721 TELECHRON AVE APT 9
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-3421
Practice Address - Country:US
Practice Address - Phone:562-278-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72529126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72529Medicaid