Healthcare Provider Details

I. General information

NPI: 1114091162
Provider Name (Legal Business Name): JAIRO GIOVANNI SEPULVEDA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAIRO GIOVANNI SEPULVEDA D.D.S

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 S MIRAGE AVE
LINDSAY CA
93247-2543
US

IV. Provider business mailing address

233 S MIRAGE AVE
LINDSAY CA
93247-2543
US

V. Phone/Fax

Practice location:
  • Phone: 559-562-5969
  • Fax: 559-562-2358
Mailing address:
  • Phone: 559-562-5969
  • Fax: 559-562-2358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number49802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: