Healthcare Provider Details

I. General information

NPI: 1417494089
Provider Name (Legal Business Name): YANETT ENRIQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 E WASHINGTON BLVD APT 31
PASADENA CA
91104-1840
US

IV. Provider business mailing address

2211 E WASHINGTON BLVD APT 31
PASADENA CA
91104-1840
US

V. Phone/Fax

Practice location:
  • Phone: 626-822-1056
  • Fax:
Mailing address:
  • Phone: 626-822-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number72393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: