Provider Demographics
NPI:1366715062
Name:HURTADO, RUBEN
Entity type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:HURTADO
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 1:15655 HAWTHORNE BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2665
Mailing Address - Country:US
Mailing Address - Phone:424-297-0513
Mailing Address - Fax:
Practice Address - Street 1:15655 HAWTHORNE BLVD
Practice Address - Street 2:STE. A
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2665
Practice Address - Country:US
Practice Address - Phone:424-297-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-12
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist