Provider Demographics
NPI:1659134450
Name:CERVANTES, IRIS MICHELLE (RDA)
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:MICHELLE
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 1/2 BURGER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-2694
Mailing Address - Country:US
Mailing Address - Phone:323-527-2886
Mailing Address - Fax:
Practice Address - Street 1:507 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2621
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA98901126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant