MEDICARE: JAMIE ROSE TANCIATCO DE LEON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	37028	CA

General Provider Information

NPI Number	:	1275357097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE ROSE TANCIATCO DE LEON

Provider Business Mailing Address
First Line	:	784 VADA ST UNIT 1
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6456
Country	:	US
Telephone Number	:	619-991-4005
Fax Number	:

Provider Business Practice Location Address
First Line	:	2835 HIGHLAND AVE
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-7404
Country	:	US
Telephone Number	:	209-683-5640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2024
Last Update Date	:	11/08/2024

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