Provider Demographics
NPI:1386292472
Name:PASTOR, ROMMEL LATO (RDA)
Entity type:Individual
Prefix:
First Name:ROMMEL
Middle Name:LATO
Last Name:PASTOR
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 VASSAR ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2936
Mailing Address - Country:US
Mailing Address - Phone:310-408-9892
Mailing Address - Fax:
Practice Address - Street 1:1839 VASSAR ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2936
Practice Address - Country:US
Practice Address - Phone:310-408-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85423126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA85423Medicaid