Provider Demographics
NPI:1053876094
Name:JUAREZ HERNANDEZ, ANGELICA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:JUAREZ HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 N 10TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4396
Mailing Address - Country:US
Mailing Address - Phone:442-258-4031
Mailing Address - Fax:
Practice Address - Street 1:1450 N IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1314
Practice Address - Country:US
Practice Address - Phone:760-679-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1035271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice