Provider Demographics
NPI:1891154282
Name:ATTALLA, ERENE
Entity Type:Individual
Prefix:
First Name:ERENE
Middle Name:
Last Name:ATTALLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 LATIGO LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36068 HIDDEN SPRINGS RD
Practice Address - Street 2:STE H
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7679
Practice Address - Country:US
Practice Address - Phone:951-579-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS101059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program