Provider Demographics
NPI:1093836868
Name:ENDONILA, ROSE JOY TEJADA
Entity Type:Individual
Prefix:DR
First Name:ROSE JOY
Middle Name:TEJADA
Last Name:ENDONILA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ROSE JOY
Other - Middle Name:GOMEZ
Other - Last Name:TEJADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1803 MONUMENT BLVD
Mailing Address - Street 2:STE# 3F
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3874
Mailing Address - Country:US
Mailing Address - Phone:925-726-2477
Mailing Address - Fax:925-726-2479
Practice Address - Street 1:1803 MONUMENT BLVD
Practice Address - Street 2:STE# 3F
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-3874
Practice Address - Country:US
Practice Address - Phone:925-726-2477
Practice Address - Fax:925-726-2479
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA448671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0479154OtherTIN#