=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972217800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RUIZ ORNELAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2023
-----------------------------------------------------
Last Update Date | 01/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 W BEVERLY BLVD STE 201
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-622-6227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 N MONTE VISTA ST
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-501-8407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 107990
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------