MEDICARE: JED DE LA PAZ LLC

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	261QD0000X	Dental Clinic/Center	60772163	WA

General Provider Information

NPI Number	:	1366959009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JED DE LA PAZ LLC

Provider Business Mailing Address
First Line	:	15 OREGON AVE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7461
Country	:	US
Telephone Number	:	253-475-0262
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 OREGON AVE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7461
Country	:	US
Telephone Number	:	253-475-0262
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. JED D DE LA PAZ
Credential	:	DDS
Telephone Number	:	626-641-8214

Provider Enumeration Date	:	01/03/2018
Last Update Date	:	01/03/2018

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