Provider Demographics
NPI:1194365882
Name:SEPULVEDA, MARIA GUADALUPE (REGISTERED DENTAL A)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GUADALUPE
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:REGISTERED DENTAL A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22675 STROHM DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-1649
Mailing Address - Country:US
Mailing Address - Phone:714-984-7938
Mailing Address - Fax:
Practice Address - Street 1:3380 LA SIERRA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5271
Practice Address - Country:US
Practice Address - Phone:951-465-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
75275126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant