Provider Demographics
NPI:1184722365
Name:MA, AUDREY S (DDS)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:S
Last Name:MA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10681 BOLSA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5270
Mailing Address - Country:US
Mailing Address - Phone:714-554-8970
Mailing Address - Fax:
Practice Address - Street 1:10681 BOLSA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-5270
Practice Address - Country:US
Practice Address - Phone:714-554-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice