Provider Demographics
NPI:1942687942
Name:MAGNO, KHAREZA
Entity Type:Individual
Prefix:
First Name:KHAREZA
Middle Name:
Last Name:MAGNO
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 1:8266 STATION VILLAGE LN APT 2610
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5590
Mailing Address - Country:US
Mailing Address - Phone:619-362-5903
Mailing Address - Fax:
Practice Address - Street 1:5059 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3348
Practice Address - Country:US
Practice Address - Phone:619-583-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28622124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist