Provider Demographics
NPI:1629707997
Name:AVILES, ROBERT R
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:AVILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7426 TYLER LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5431
Mailing Address - Country:US
Mailing Address - Phone:909-518-5010
Mailing Address - Fax:
Practice Address - Street 1:7426 TYLER LN
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5431
Practice Address - Country:US
Practice Address - Phone:909-518-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP938124Q00000X
CA26819124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty