Provider Demographics
NPI:1174837538
Name:VITEZ, JENNIFER L (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:VITEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 N FAIR OAKS AVE
Mailing Address - Street 2:ST 1101
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1845 N FAIR OAKS AVE
Practice Address - Street 2:ST. 1101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1620
Practice Address - Country:US
Practice Address - Phone:626-744-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist