Provider Demographics
NPI:1982894804
Name:BLANCO, NUBIA AUXILIADORA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NUBIA
Middle Name:AUXILIADORA
Last Name:BLANCO
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 1:1410 SPRUCE TREE DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2571
Mailing Address - Country:US
Mailing Address - Phone:909-612-0719
Mailing Address - Fax:909-456-0607
Practice Address - Street 1:1410 SPRUCE TREE DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2571
Practice Address - Country:US
Practice Address - Phone:909-612-0719
Practice Address - Fax:909-456-0607
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice