Healthcare Provider Details

I. General information

NPI: 1265962773
Provider Name (Legal Business Name): JORGE H. ZAMUDIO DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2017
Last Update Date: 06/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 3RD ST. SUITE 4
RIVERSIDE CA
92507
US

IV. Provider business mailing address

1410 3RD ST. SUITE 4
RIVERSIDE CA
92507
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8783
  • Fax: 951-686-8784
Mailing address:
  • Phone: 951-686-8783
  • Fax: 951-686-8784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number45873
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JORGE HERNANDEZ-ZAMUDIO
Title or Position: OWNER/CEO
Credential:
Phone: 951-318-1740