Provider Demographics
NPI:1255813416
Name:GUZMAN GARCIA, DIEGO JESUS
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:JESUS
Last Name:GUZMAN GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13137 ADELINE AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5930
Mailing Address - Country:US
Mailing Address - Phone:626-722-2097
Mailing Address - Fax:
Practice Address - Street 1:13137 ADELINE AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5930
Practice Address - Country:US
Practice Address - Phone:626-722-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOA48872126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOA48872Medicaid