Provider Demographics
NPI:1700281268
Name:JESSICA ILAGAN AVERGONZADO,D.D.S., INC
Entity Type:Organization
Organization Name:JESSICA ILAGAN AVERGONZADO,D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ILAGAN
Authorized Official - Last Name:AVERGONZADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-804-7580
Mailing Address - Street 1:13424 WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-2629
Mailing Address - Country:US
Mailing Address - Phone:562-804-7580
Mailing Address - Fax:562-916-3397
Practice Address - Street 1:13424 WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2629
Practice Address - Country:US
Practice Address - Phone:562-804-7580
Practice Address - Fax:562-916-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty