Healthcare Provider Details

I. General information

NPI: 1356718217
Provider Name (Legal Business Name): JENNIFER WEITZEL RDHAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 LIPPIZAN DR
RIVERSIDE CA
92509-5326
US

IV. Provider business mailing address

7611 LIPPIZAN DR
RIVERSIDE CA
92509-5326
US

V. Phone/Fax

Practice location:
  • Phone: 951-660-7019
  • Fax: 951-332-0186
Mailing address:
  • Phone: 951-660-7019
  • Fax: 951-332-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: