Provider Demographics
NPI:1699957696
Name:FAJARDO, JOSE AGAPITO TIU JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE AGAPITO
Middle Name:TIU
Last Name:FAJARDO
Suffix:JR
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 1:10920 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2515
Mailing Address - Country:US
Mailing Address - Phone:626-582-8818
Mailing Address - Fax:
Practice Address - Street 1:10920 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2515
Practice Address - Country:US
Practice Address - Phone:626-582-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA565871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689982050OtherMEDI-CAL