Healthcare Provider Details

I. General information

NPI: 1467776450
Provider Name (Legal Business Name): JUAN CARLOS HUAMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15424 CHASE ST APT 5
NORTH HILLS CA
91343-6565
US

IV. Provider business mailing address

620 W YOSEMITE AVE
MADERA CA
93637-4523
US

V. Phone/Fax

Practice location:
  • Phone: 818-442-1473
  • Fax:
Mailing address:
  • Phone: 559-673-7700
  • Fax: 559-673-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: