Provider Demographics
NPI:1427124171
Name:SY-PRUDENCIO, CARMELITA A (DMD)
Entity type:Individual
Prefix:DR
First Name:CARMELITA
Middle Name:A
Last Name:SY-PRUDENCIO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31099 KAHWEA ST
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-1790
Mailing Address - Country:US
Mailing Address - Phone:951-676-6122
Mailing Address - Fax:
Practice Address - Street 1:29760 RANCHO CALIFORNIA RD
Practice Address - Street 2:SUITE 108
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5288
Practice Address - Country:US
Practice Address - Phone:951-693-5220
Practice Address - Fax:951-693-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA411311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice