Healthcare Provider Details

I. General information

NPI: 1588853352
Provider Name (Legal Business Name): JESUSA BEATRIZ PEREZ KELLY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8788 JAMACHA RD
SPRING VALLEY CA
91977-4035
US

IV. Provider business mailing address

PO BOX 262202
SAN DIEGO CA
92196-2202
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2555
  • Fax:
Mailing address:
  • Phone: 858-622-0085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: