Basic Information
| Provider Information | |||||||||
| NPI: | 1639474380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNOZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1052 W 43RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900372403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232320068 | ||||||||
| FaxNumber: | 3232320068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SAN FERNANDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913403115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183658086 | ||||||||
| FaxNumber: | 8188984826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2011 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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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 | 124Q00000X | 25278 | CA | Y | Dental Providers | Dental Hygienist |
No ID Information.