Provider Demographics
NPI:1861038713
Name:VASQUEZ, ISAIAH DARIAN (RDA)
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:DARIAN
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 BIRCHCREST RD APT E104
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90240-2107
Mailing Address - Country:US
Mailing Address - Phone:562-565-7479
Mailing Address - Fax:
Practice Address - Street 1:9910 LONG BEACH BLVD STE A
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-1561
Practice Address - Country:US
Practice Address - Phone:323-538-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93763126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93763Medicaid