Provider Demographics
NPI:1992291983
Name:AMIGON, GENESSIS SARAHI (RDA)
Entity type:Individual
Prefix:
First Name:GENESSIS
Middle Name:SARAHI
Last Name:AMIGON
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:GENESSIS
Other - Middle Name:SARAHI
Other - Last Name:ALVARADO CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDA
Mailing Address - Street 1:16424 CERES AVE APT 312
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-2374
Mailing Address - Country:US
Mailing Address - Phone:909-368-4340
Mailing Address - Fax:
Practice Address - Street 1:1160 E ONTARIO AVE STE 103
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-8653
Practice Address - Country:US
Practice Address - Phone:951-547-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90024126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant