Provider Demographics
NPI:1447006770
Name:PEREZ VILLAGOMEZ, MARIO ALBERTO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ALBERTO
Last Name:PEREZ VILLAGOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 CARMENITA RD APT 301
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-3849
Mailing Address - Country:US
Mailing Address - Phone:442-599-1376
Mailing Address - Fax:
Practice Address - Street 1:709 W BEVERLY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3600
Practice Address - Country:US
Practice Address - Phone:323-724-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist