Provider Demographics
NPI:1073660403
Name:JACINTO, RUDELL GARY SANTOS (DMD)
Entity Type:Individual
Prefix:
First Name:RUDELL GARY
Middle Name:SANTOS
Last Name:JACINTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 WILSHIRE BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-6104
Mailing Address - Country:US
Mailing Address - Phone:323-931-1385
Mailing Address - Fax:323-931-2728
Practice Address - Street 1:5001 WILSHIRE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-6104
Practice Address - Country:US
Practice Address - Phone:323-931-1385
Practice Address - Fax:323-931-2728
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist