Provider Demographics
NPI:1780369884
Name:MACIAS, BLANCA ERICA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:ERICA
Last Name:MACIAS
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 1:661 W 1ST ST STE G
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2939
Mailing Address - Country:US
Mailing Address - Phone:714-665-9890
Mailing Address - Fax:714-665-9891
Practice Address - Street 1:661 W 1ST ST STE G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28996124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist