Provider Demographics
NPI:1063879559
Name:PATRICIA M. JAQUEZ, DMD PA
Entity type:Organization
Organization Name:PATRICIA M. JAQUEZ, DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JAQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-430-0308
Mailing Address - Street 1:12297 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1725
Mailing Address - Country:US
Mailing Address - Phone:954-430-0308
Mailing Address - Fax:
Practice Address - Street 1:12297 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1725
Practice Address - Country:US
Practice Address - Phone:954-430-0308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN175931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty