Provider Demographics
NPI:1366959009
Name:JED DE LA PAZ LLC
Entity type:Organization
Organization Name:JED DE LA PAZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JED
Authorized Official - Middle Name:D
Authorized Official - Last Name:DE LA PAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-641-8214
Mailing Address - Street 1:15 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7461
Mailing Address - Country:US
Mailing Address - Phone:253-475-0262
Mailing Address - Fax:
Practice Address - Street 1:15 OREGON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7461
Practice Address - Country:US
Practice Address - Phone:253-475-0262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60772163261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental