Provider Demographics
NPI:1144062134
Name:VALENZUELA, DYLAN ROGER (MA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:ROGER
Last Name:VALENZUELA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N ROOSEVELT AVE UNIT 36
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2644
Mailing Address - Country:US
Mailing Address - Phone:480-901-3163
Mailing Address - Fax:
Practice Address - Street 1:4121 E VALLEY AUTO DR STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4632
Practice Address - Country:US
Practice Address - Phone:623-715-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager