Healthcare Provider Details

I. General information

NPI: 1619279932
Provider Name (Legal Business Name): JENNY LOU GULARTE R.D.H., O.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12209 BRASSICA ST
SAN DIEGO CA
92129-4125
US

IV. Provider business mailing address

12209 BRASSICA ST
SAN DIEGO CA
92129-4125
US

V. Phone/Fax

Practice location:
  • Phone: 858-484-6006
  • Fax: 858-484-6001
Mailing address:
  • Phone: 858-484-6006
  • Fax: 858-484-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH9314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: