Provider Demographics
NPI:1497970883
Name:CAMARENA, JUAN A (DDS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:A
Last Name:CAMARENA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8311 HAVEN AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3867
Mailing Address - Country:US
Mailing Address - Phone:909-983-7707
Mailing Address - Fax:909-984-2261
Practice Address - Street 1:8311 HAVEN AVE STE 230
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3867
Practice Address - Country:US
Practice Address - Phone:909-983-7707
Practice Address - Fax:909-984-2261
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB26353-01Medicaid
CA519060Medicaid