Provider Demographics
NPI:1194373415
Name:CHAIDEZ-REDMILES, JOSE C (RDH)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:C
Last Name:CHAIDEZ-REDMILES
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 LONG BEACH BLVD APT 221
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3297
Mailing Address - Country:US
Mailing Address - Phone:562-912-5688
Mailing Address - Fax:
Practice Address - Street 1:507 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:EAST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2621
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32984124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist