Provider Demographics
NPI:1255763744
Name:MASSENA, AUDRA CHARLENE (RDH)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:CHARLENE
Last Name:MASSENA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5468 E SUNCREST RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3743
Mailing Address - Country:US
Mailing Address - Phone:714-504-2945
Mailing Address - Fax:
Practice Address - Street 1:5468 E SUNCREST RD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3743
Practice Address - Country:US
Practice Address - Phone:714-504-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24996124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist