Healthcare Provider Details

I. General information

NPI: 1568609642
Provider Name (Legal Business Name): JESUS ANTONIO SAMANIEGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13235 BARLIN AVE
DOWNEY CA
90242-5103
US

IV. Provider business mailing address

13235 BARLIN AVE
DOWNEY CA
90242-5103
US

V. Phone/Fax

Practice location:
  • Phone: 562-970-8612
  • Fax:
Mailing address:
  • Phone: 562-970-8612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number4490492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: