Healthcare Provider Details

I. General information

NPI: 1639088230
Provider Name (Legal Business Name): JESENIA GUADALUPE LINARES MOCTEZUMA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ANCHORAGE POINT DR
WARSAW IN
46580-2282
US

IV. Provider business mailing address

258 EMS T25 LN
LEESBURG IN
46538-8931
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13009831A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: