Provider Demographics
NPI:1053121434
Name:PACHECO UITZ, JOAQUIN DONALDO
Entity type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:DONALDO
Last Name:PACHECO UITZ
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 1:3911 W 104TH ST APT 28
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-5811
Mailing Address - Country:US
Mailing Address - Phone:424-224-3659
Mailing Address - Fax:424-224-3659
Practice Address - Street 1:3911 W 104TH ST APT 28
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-5811
Practice Address - Country:US
Practice Address - Phone:424-224-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1111511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice