Provider Demographics
NPI:1891241394
Name:CASTRO IMUL, ANTOLIN (RDA)
Entity Type:Individual
Prefix:
First Name:ANTOLIN
Middle Name:
Last Name:CASTRO IMUL
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 1:446 LINDEN AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2521
Mailing Address - Country:US
Mailing Address - Phone:562-753-7806
Mailing Address - Fax:
Practice Address - Street 1:5162 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3932
Practice Address - Country:US
Practice Address - Phone:323-415-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68991126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68991Medicaid