Provider Demographics
NPI:1568163319
Name:HEREDIA, MINERVA LETICIA
Entity Type:Individual
Prefix:
First Name:MINERVA
Middle Name:LETICIA
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 SUNNYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-6919
Mailing Address - Country:US
Mailing Address - Phone:714-742-6812
Mailing Address - Fax:
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3576
Practice Address - Country:US
Practice Address - Phone:657-282-6355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP703124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist