Provider Demographics
NPI:1962640144
Name:CISNEROS, ARIEL
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 MAR VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4940
Mailing Address - Country:US
Mailing Address - Phone:310-549-1826
Mailing Address - Fax:
Practice Address - Street 1:21229 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5501
Practice Address - Country:US
Practice Address - Phone:310-792-5600
Practice Address - Fax:310-792-5628
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2815126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2815OtherDENTAL ASSISTANT