Provider Demographics
NPI:1124583091
Name:ENRIQUEZ PACHECO, GUADALUPE
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:ENRIQUEZ PACHECO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-6027
Mailing Address - Country:US
Mailing Address - Phone:323-384-6375
Mailing Address - Fax:
Practice Address - Street 1:2601 DIXIE ST
Practice Address - Street 2:
Practice Address - City:ROSAMOND
Practice Address - State:CA
Practice Address - Zip Code:93560-6027
Practice Address - Country:US
Practice Address - Phone:323-384-6375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA71318126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant