Provider Demographics
NPI:1568732725
Name:CUSTODIA, GENELLE MORALES (RDH)
Entity Type:Individual
Prefix:
First Name:GENELLE
Middle Name:MORALES
Last Name:CUSTODIA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26969 ORCHID AVE
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-4135
Mailing Address - Country:US
Mailing Address - Phone:714-988-3164
Mailing Address - Fax:
Practice Address - Street 1:10602 CHAPMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-3147
Practice Address - Country:US
Practice Address - Phone:714-638-7637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26412124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist