Provider Demographics
NPI:1083031017
Name:MONCADA LULE, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MONCADA LULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 WILLOWBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1509
Mailing Address - Country:US
Mailing Address - Phone:310-923-1873
Mailing Address - Fax:
Practice Address - Street 1:2717 WILLOWBROOK AVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1509
Practice Address - Country:US
Practice Address - Phone:310-923-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant