Provider Demographics
NPI:1952841389
Name:VILLALTA, JENNIFER (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12555 W JEFFERSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-7032
Mailing Address - Country:US
Mailing Address - Phone:310-439-1751
Mailing Address - Fax:310-439-1752
Practice Address - Street 1:12555 W JEFFERSON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7032
Practice Address - Country:US
Practice Address - Phone:310-439-1751
Practice Address - Fax:310-439-1752
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1042581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry