Healthcare Provider Details

I. General information

NPI: 1053920777
Provider Name (Legal Business Name): MISS JULIE R QUEVEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4733 KARLING PL
PALMDALE CA
93552-4462
US

IV. Provider business mailing address

4733 KARLING PL
PALMDALE CA
93552-4462
US

V. Phone/Fax

Practice location:
  • Phone: 818-618-9719
  • Fax:
Mailing address:
  • Phone: 818-618-9719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number90611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: