Basic Information
| Provider Information | |||||||||
| NPI: | 1205010543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOJICA-JARA | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 STOCKTON BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958205455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164556600 | ||||||||
| FaxNumber: | 9164554638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3609 MISSION AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956082955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164885781 | ||||||||
| FaxNumber: | 9164885973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2007 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D56569 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G90179-53 | 05 | CA | MEDICAID |