Provider Demographics
NPI:1578720363
Name:GUADALUPE, AIDA MIRASOL (DDS)
Entity Type:Individual
Prefix:DR
First Name:AIDA
Middle Name:MIRASOL
Last Name:GUADALUPE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1794 WHIPPLE RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1927
Mailing Address - Country:US
Mailing Address - Phone:510-324-4002
Mailing Address - Fax:510-324-4024
Practice Address - Street 1:1794 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1927
Practice Address - Country:US
Practice Address - Phone:510-324-4002
Practice Address - Fax:510-324-4024
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40825122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist