Provider Demographics
NPI:1649295320
Name:VILLASENOR, JORGE A (DDS)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:VILLASENOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JORGE
Other - Middle Name:A
Other - Last Name:VILLASENOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4161 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-1966
Mailing Address - Country:US
Mailing Address - Phone:626-579-4274
Mailing Address - Fax:626-579-4294
Practice Address - Street 1:445 S NEW HAMPSHIRE AVE
Practice Address - Street 2:310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1950
Practice Address - Country:US
Practice Address - Phone:213-382-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA389381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice