Provider Demographics
NPI:1386427789
Name:VELASCO, IDALIA ROSA (RDH)
Entity type:Individual
Prefix:
First Name:IDALIA
Middle Name:ROSA
Last Name:VELASCO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4129 1/2 BEMIS ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1215
Mailing Address - Country:US
Mailing Address - Phone:323-574-3927
Mailing Address - Fax:
Practice Address - Street 1:9000 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5002
Practice Address - Country:US
Practice Address - Phone:310-287-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20690124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist