Healthcare Provider Details

I. General information

NPI: 1679710743
Provider Name (Legal Business Name): JULIO CESAR ESCOBEDO RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4149 TWEEDY BLVD STE J
SOUTH GATE CA
90280-6167
US

IV. Provider business mailing address

9841 MADISON AVE APT C
SOUTH GATE CA
90280-4341
US

V. Phone/Fax

Practice location:
  • Phone: 323-567-3333
  • Fax:
Mailing address:
  • Phone: 323-572-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number70766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: