Healthcare Provider Details

I. General information

NPI: 1588227185
Provider Name (Legal Business Name): JACQUELYN DO DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12835 POINTE DEL MAR WAY STE 2
DEL MAR CA
92014-3846
US

IV. Provider business mailing address

12835 POINTE DEL MAR WAY STE 2
DEL MAR CA
92014-3846
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-0050
  • Fax: 858-755-0059
Mailing address:
  • Phone: 858-755-0050
  • Fax: 858-755-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELYN DO
Title or Position: PRINCIPAL
Credential:
Phone: 858-755-0050