Provider Demographics
NPI:1740770247
Name:AVILES, JEANNETTE LISA (RDHAP)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:LISA
Last Name:AVILES
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11198 TERRA VISTA PKWY APT 112
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7422
Mailing Address - Country:US
Mailing Address - Phone:909-279-8558
Mailing Address - Fax:
Practice Address - Street 1:11198 TERRA VISTA PKWY APT 112
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7422
Practice Address - Country:US
Practice Address - Phone:909-279-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty