Provider Demographics
NPI:1215694955
Name:BECERRA-LISING, JACQUELINE (RDH)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BECERRA-LISING
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6939 SCHAEFER AVENUE STE D, #314
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-702-6745
Mailing Address - Fax:
Practice Address - Street 1:6955 ANGORA ST
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-8351
Practice Address - Country:US
Practice Address - Phone:909-702-6745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21913124Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist