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General NPI Number Information
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NPI Number | 1265034409
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Entity Type | Individual
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Provider Name | SELINA JADE PRESTON CSOM
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Gender | Female
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Dates
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Enumeration Date | 11/12/2020
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Last Update Date | 11/01/2021
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Provider Practice Location Address
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Address Line | 16767 BERNARDO CENTER DR # 27384
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City | SAN DIEGO
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State | CA
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Zip | 92128-2509
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Country | US
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Telephone | 858-848-9660
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Fax |
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Provider Business Mailing Address
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Address Line | 16767 BERNARDO CENTER DR # 27384
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City | SAN DIEGO
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State | CA
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Zip | 92128-2509
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Country | US
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Telephone | 858-848-9660
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 31496
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | CA
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