=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164114146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIR SOLIS LOPEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2023
-----------------------------------------------------
Last Update Date | 07/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 B ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95334-9593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-710-5747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 B ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95334-9593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-710-5747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 111601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------