Provider Demographics
NPI:1871223800
Name:PALACIOS, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 NW 107TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4377
Mailing Address - Country:US
Mailing Address - Phone:305-418-7771
Mailing Address - Fax:
Practice Address - Street 1:295 W VALENCIA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-7046
Practice Address - Country:US
Practice Address - Phone:520-573-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD011943.122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASTUDENTMedicaid