Provider Demographics
NPI:1639474380
Name:MUNOZ, JACQUELINE (RDH)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 W 43RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2403
Mailing Address - Country:US
Mailing Address - Phone:323-232-0068
Mailing Address - Fax:323-232-0068
Practice Address - Street 1:1600 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3115
Practice Address - Country:US
Practice Address - Phone:818-365-8086
Practice Address - Fax:818-898-4826
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25278124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist