Provider Demographics
NPI:1215935564
Name:MONCADA, MARCELO GENESTON (DDS)
Entity type:Individual
Prefix:DR
First Name:MARCELO
Middle Name:GENESTON
Last Name:MONCADA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 N VERMONT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6307
Mailing Address - Country:US
Mailing Address - Phone:323-663-7897
Mailing Address - Fax:323-663-7803
Practice Address - Street 1:1321 N VERMONT AVE
Practice Address - Street 2:STE. B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6307
Practice Address - Country:US
Practice Address - Phone:323-663-7897
Practice Address - Fax:323-663-7803
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA436431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB43643-01OtherMEDI-CAL