Healthcare Provider Details

I. General information

NPI: 1972681104
Provider Name (Legal Business Name): JETTIE UYANNE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9474 FIRESTONE BLVD SMILE CARE
DOWNEY CA
90241
US

IV. Provider business mailing address

12640 BEACH STREET
CERRITOS CA
90703
US

V. Phone/Fax

Practice location:
  • Phone: 562-803-4224
  • Fax:
Mailing address:
  • Phone: 562-802-7979
  • Fax: 562-802-7979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: