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General NPI Number Information
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NPI Number | 1700281268
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Entity Type | Organization
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Legal Business Name | JESSICA ILAGAN AVERGONZADO,D.D.S., INC
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Dates
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Enumeration Date | 10/27/2014
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Last Update Date | 10/27/2014
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Provider Practice Location Address
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Address Line | 13424 WOODRUFF AVE
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City | BELLFLOWER
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State | CA
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Zip | 90706-2629
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Country | US
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Telephone | 562-804-7580
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Fax | 562-916-3397
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Provider Business Mailing Address
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Address Line | 13424 WOODRUFF AVE
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City | BELLFLOWER
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State | CA
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Zip | 90706-2629
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Country | US
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Telephone | 562-804-7580
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Fax | 562-916-3397
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JESSICA ILAGAN AVERGONZADO
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Credential |
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Telephone | 562-804-7580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 49338
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License Number State | CA
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