Provider Demographics
NPI:1235456823
Name:CAMACHO, JESENIA
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:CAMACHO
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 1:15120 PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-6449
Mailing Address - Country:US
Mailing Address - Phone:562-440-8544
Mailing Address - Fax:
Practice Address - Street 1:1212 WILSHIRE BLVD
Practice Address - Street 2:1111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1902
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02177895126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant