Provider Demographics
NPI:1124349311
Name:PERALTA, GRICELDA (RDH, RDHAP)
Entity type:Individual
Prefix:
First Name:GRICELDA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:RDH, RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 CULVER BLVD
Mailing Address - Street 2:SUITE 187
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7704
Mailing Address - Country:US
Mailing Address - Phone:310-779-9712
Mailing Address - Fax:
Practice Address - Street 1:322 CULVER BLVD
Practice Address - Street 2:SUITE 187
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7704
Practice Address - Country:US
Practice Address - Phone:310-779-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296124Q00000X
CA18576124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist