Provider Demographics
NPI:1265034409
Name:PRESTON, SELINA JADE (CSOM)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:JADE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:CSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16767 BERNARDO CENTER DR # 27384
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2509
Mailing Address - Country:US
Mailing Address - Phone:858-848-9660
Mailing Address - Fax:
Practice Address - Street 1:16767 BERNARDO CENTER DR # 27384
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2509
Practice Address - Country:US
Practice Address - Phone:858-848-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31496124Q00000X
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty