Individual
MS. ERICA BERENICE LICEA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RDA ORTHO ASSISTANT
Contact information
Practice address
1342 W LA GLORIA DR, RIALTO, CA 92377-4466
(951) 465-9162
Mailing address
1342 W LA GLORIA DR, RIALTO, CA 92377-4466
(951) 465-9162
Taxonomy
Speciality
Code
Description
License number
State
126800000X
Dental Assistant
Primary
66604
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
66604
—
CA
Enumeration date
03/19/2019
Last updated
03/19/2019
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