Provider Demographics
NPI:1336752971
Name:RUBIO, MAURICIO
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:RUBIO
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 1:5336 E TRUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93725-0934
Mailing Address - Country:US
Mailing Address - Phone:559-824-3188
Mailing Address - Fax:
Practice Address - Street 1:5336 E TRUMAN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93725-0934
Practice Address - Country:US
Practice Address - Phone:559-824-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty