=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417744350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAN VASQUEZ DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 N EUCLID ST
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92801-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-967-8811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 AUBURN CT STE 3
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-967-8811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | DR. RYANN VASQUEZ
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 909-967-8811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------