Provider Demographics
NPI:1356718217
Name:WEITZEL, JENNIFER (RDHAP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEITZEL
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 1:7611 LIPPIZAN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-5326
Mailing Address - Country:US
Mailing Address - Phone:951-660-7019
Mailing Address - Fax:951-332-0186
Practice Address - Street 1:7611 LIPPIZAN DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-5326
Practice Address - Country:US
Practice Address - Phone:951-660-7019
Practice Address - Fax:951-332-0186
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA577124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist