Provider Demographics
NPI:1447748199
Name:SALAPONG, MARY JANE DE LEON (RDA)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:DE LEON
Last Name:SALAPONG
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 1:34094 LADY FERN CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2940
Mailing Address - Country:US
Mailing Address - Phone:949-483-0369
Mailing Address - Fax:
Practice Address - Street 1:2440 RIVER RD STE 140
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2402
Practice Address - Country:US
Practice Address - Phone:888-904-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA58343126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA58343Medicaid