Healthcare Provider Details

I. General information

NPI: 1104911502
Provider Name (Legal Business Name): JESUS HUMBERTO GUZMAN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13177 OSBORNE ST.
PACOIMA CA
91331-4019
US

IV. Provider business mailing address

13177 OSBORNE ST.
PACOIMA CA
91331-4019
US

V. Phone/Fax

Practice location:
  • Phone: 818-897-0445
  • Fax: 818-834-2261
Mailing address:
  • Phone: 818-897-0445
  • Fax: 818-834-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: