Provider Demographics
NPI:1821473240
Name:VALLE, ANDREA AMANDA (RDH, BSDH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:AMANDA
Last Name:VALLE
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 WAKE FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1224
Mailing Address - Country:US
Mailing Address - Phone:909-706-1001
Mailing Address - Fax:
Practice Address - Street 1:1311 WAKE FOREST AVE
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-1224
Practice Address - Country:US
Practice Address - Phone:909-706-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28848124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist