Healthcare Provider Details

I. General information

NPI: 1558787416
Provider Name (Legal Business Name): JEMILYN VELASCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 03/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N FLOWER ST
SANTA ANA CA
92703-2361
US

IV. Provider business mailing address

1160 STARBRIGHT DR
CORONA CA
92882-8338
US

V. Phone/Fax

Practice location:
  • Phone: 714-647-4148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number58764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: