Provider Demographics
NPI:1194964437
Name:VELAZQUEZ, RAUL (DMD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE # 307
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1524
Mailing Address - Country:US
Mailing Address - Phone:310-478-9393
Mailing Address - Fax:310-478-5579
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:SUITE # 307
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:310-478-9393
Practice Address - Fax:310-478-5579
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice