=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093229114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAIRO SEPULVEDA DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2017
-----------------------------------------------------
Last Update Date | 11/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 S MIRAGE AVE
-----------------------------------------------------
City | LINDSAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93247-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-562-5969
-----------------------------------------------------
Fax | 559-562-2358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 S MIRAGE AVE
-----------------------------------------------------
City | LINDSAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93247-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-562-5969
-----------------------------------------------------
Fax | 559-562-2358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/ OWNER
-----------------------------------------------------
Name | DR. JAIRO GIOVANNI SEPULVEDA
-----------------------------------------------------
Credential | DENTIST
-----------------------------------------------------
Telephone | 559-562-5969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 49802
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------