Provider Demographics
NPI:1992051098
Name:CORTEZ, MICHELLE LYNNE (RDA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNNE
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:LYNNE
Other - Last Name:FELLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDA
Mailing Address - Street 1:4000 LA RICA AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3163
Mailing Address - Country:US
Mailing Address - Phone:626-347-5645
Mailing Address - Fax:
Practice Address - Street 1:4000 LA RICA AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3163
Practice Address - Country:US
Practice Address - Phone:626-347-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA63963126800000X
CA63963126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant