Healthcare Provider Details

I. General information

NPI: 1679123319
Provider Name (Legal Business Name): PATRICE H DEMENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2019
Last Update Date: 09/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 SPRINGFIELD AVE APT B
HUNTINGTON BEACH CA
92648-3139
US

IV. Provider business mailing address

219 SPRINGFIELD AVE APT B
HUNTINGTON BEACH CA
92648-3139
US

V. Phone/Fax

Practice location:
  • Phone: 714-330-8779
  • Fax:
Mailing address:
  • Phone: 714-330-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number46979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: