Provider Demographics
NPI:1760900914
Name:PINEDA, MAURICIO (RDA III)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:PINEDA
Suffix:
Gender:M
Credentials:RDA III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 3/4 TEMPLE CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-2013
Mailing Address - Country:US
Mailing Address - Phone:562-704-8416
Mailing Address - Fax:
Practice Address - Street 1:9050 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2410
Practice Address - Country:US
Practice Address - Phone:562-456-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA86217126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA86217Medicaid