Provider Demographics
NPI:1417537069
Name:ROSALES, JONATHAN PASCUAL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PASCUAL
Last Name:ROSALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6952 SIERRA HWY
Mailing Address - Street 2:
Mailing Address - City:AGUA DULCE
Mailing Address - State:CA
Mailing Address - Zip Code:91390-4598
Mailing Address - Country:US
Mailing Address - Phone:818-483-3701
Mailing Address - Fax:
Practice Address - Street 1:6952 SIERRA HWY
Practice Address - Street 2:
Practice Address - City:AGUA DULCE
Practice Address - State:CA
Practice Address - Zip Code:91390-4598
Practice Address - Country:US
Practice Address - Phone:818-483-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA96158126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA96158Medicaid