Provider Demographics
NPI:1215533104
Name:JUAREZ, SAVANNAH
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8351
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-1551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3380 LA SIERRA AVE STE 108
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5225
Practice Address - Country:US
Practice Address - Phone:424-209-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33357Medicaid