Provider Demographics
NPI:1790432722
Name:MENJIVAR, JOSUE EMANUEL (RDH)
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:EMANUEL
Last Name:MENJIVAR
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3254
Mailing Address - Fax:805-929-6359
Practice Address - Street 1:150 TEJAS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9123
Practice Address - Country:US
Practice Address - Phone:805-929-3254
Practice Address - Fax:805-929-6359
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH34547124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist