Provider Demographics
NPI:1093229114
Name:JAIRO SEPULVEDA DDS, INC.
Entity Type:Organization
Organization Name:JAIRO SEPULVEDA DDS, INC.
Other - Org Name:JAIRO SEPULVEDA DDS, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIRO
Authorized Official - Middle Name:GIOVANNI
Authorized Official - Last Name:SEPULVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:559-562-5969
Mailing Address - Street 1:233 S MIRAGE AVE
Mailing Address - Street 2:
Mailing Address - City:LINDSAY
Mailing Address - State:CA
Mailing Address - Zip Code:93247-2543
Mailing Address - Country:US
Mailing Address - Phone:559-562-5969
Mailing Address - Fax:559-562-2358
Practice Address - Street 1:233 S MIRAGE AVE
Practice Address - Street 2:
Practice Address - City:LINDSAY
Practice Address - State:CA
Practice Address - Zip Code:93247-2543
Practice Address - Country:US
Practice Address - Phone:559-562-5969
Practice Address - Fax:559-562-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49802261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114091162OtherMEDICAL