=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538733407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOCELYN GONZALEZ RDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2021
-----------------------------------------------------
Last Update Date | 05/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 S VERMONT AVE STE F
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-212-5495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 E IMPERIAL HWY # 373
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90059-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-417-0033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | RDA92705
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------