Provider Demographics
NPI:1912754748
Name:MACASAET, RENARD RUIGI ANATALIO
Entity type:Individual
Prefix:MR
First Name:RENARD RUIGI
Middle Name:ANATALIO
Last Name:MACASAET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10052 FARRALONE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2708
Mailing Address - Country:US
Mailing Address - Phone:714-909-3067
Mailing Address - Fax:
Practice Address - Street 1:514 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2904
Practice Address - Country:US
Practice Address - Phone:714-909-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1106571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program