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General NPI Number Information
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NPI Number | 1801306493
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Entity Type | Individual
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Provider Name | JENNIFER K AZEVEDO RDA, OSA
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Gender | Female
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Dates
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Enumeration Date | 10/09/2017
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Last Update Date | 10/09/2017
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Provider Practice Location Address
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Address Line | 201 E ORANGEBURG AVE STE A
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City | MODESTO
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State | CA
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Zip | 95350-5355
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Country | US
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Telephone | 209-527-5050
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Fax | 209-527-0659
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Provider Business Mailing Address
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Address Line | 201 E. ORANGEBURG AVE SUITE A
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City | MODESTO
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State | CA
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Zip | 95350
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Country | US
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Telephone | 209-527-5050
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Fax | 209-527-0659
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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 | 126800000X
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Taxonomy Name | Dental Assistant
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License Number | RDS77618
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License Number State | CA
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