Provider Demographics
NPI:1689700114
Name:VILLA, GUADALUPE VELAZQUEZ (DDS)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:VELAZQUEZ
Last Name:VILLA
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 1:8310 REGENTS RD UNIT 3F
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1347
Mailing Address - Country:US
Mailing Address - Phone:619-807-8524
Mailing Address - Fax:
Practice Address - Street 1:215 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2710
Practice Address - Country:US
Practice Address - Phone:619-427-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40900OtherDENTICAL