Provider Demographics
NPI:1396285300
Name:ABUEVA, KATHLEEN MAE DELOS REYES (RDHAP)
Entity type:Individual
Prefix:
First Name:KATHLEEN MAE
Middle Name:DELOS REYES
Last Name:ABUEVA
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:KATHLEEN MAE
Other - Middle Name:JULIAN
Other - Last Name:DELOS REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:859 N WILTON PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-4057
Mailing Address - Country:US
Mailing Address - Phone:323-470-9304
Mailing Address - Fax:
Practice Address - Street 1:859 N WILTON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-4057
Practice Address - Country:US
Practice Address - Phone:323-470-9304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30858124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA729Medicaid
CA30858Medicaid