Provider Demographics
NPI:1447881875
Name:LAURIA, BETHANY ICEL ANTONIO (RDH)
Entity type:Individual
Prefix:
First Name:BETHANY ICEL
Middle Name:ANTONIO
Last Name:LAURIA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13450 S. HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5806
Mailing Address - Country:US
Mailing Address - Phone:310-679-0106
Mailing Address - Fax:310-679-6698
Practice Address - Street 1:13450 S. HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5806
Practice Address - Country:US
Practice Address - Phone:310-679-0106
Practice Address - Fax:310-679-6698
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH-31592124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist