Provider Demographics
NPI:1700806924
Name:VELAZQUEZ, ALFREDO (DDS)
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 N E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1901
Mailing Address - Country:US
Mailing Address - Phone:909-383-8328
Mailing Address - Fax:909-383-8332
Practice Address - Street 1:189 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1901
Practice Address - Country:US
Practice Address - Phone:909-383-8328
Practice Address - Fax:909-383-8332
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA441191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330985090OtherTAX ID
CA273631265OtherTAX ID