Provider Demographics
NPI:1982842456
Name:REYNOSA, MAYRA RAQUEL
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:RAQUEL
Last Name:REYNOSA
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 1:1935 E GARVEY AVE N APT 5
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1456
Mailing Address - Country:US
Mailing Address - Phone:760-222-8644
Mailing Address - Fax:
Practice Address - Street 1:1406 N AZUSA AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1257
Practice Address - Country:US
Practice Address - Phone:626-858-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant