Provider Demographics
NPI:1902487796
Name:GONZALEZ-QUIROZ, JACQUELINE (RDHAP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GONZALEZ-QUIROZ
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 1:115 S LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4346
Mailing Address - Country:US
Mailing Address - Phone:909-282-7191
Mailing Address - Fax:
Practice Address - Street 1:115 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-4346
Practice Address - Country:US
Practice Address - Phone:909-282-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP718124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist