Provider Demographics
NPI:1669863023
Name:AREVALO, JEANAE
Entity Type:Individual
Prefix:MS
First Name:JEANAE
Middle Name:
Last Name:AREVALO
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 1:2604 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-2298
Mailing Address - Country:US
Mailing Address - Phone:323-731-3333
Mailing Address - Fax:323-731-7626
Practice Address - Street 1:380 S FERRIS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1921
Practice Address - Country:US
Practice Address - Phone:818-523-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83365126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant