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Provider Information for 1982759866

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1982759866

Calendar   Last Updated:  2013-01-16
  Certification Date: 


Name Value
NPI 1982759866
Enumeration Date 2007-01-24
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1837 CAMINO MOJAVE
CHULA VISTA, CA 91914-4616
United States

Phone: 619-216-3092 | Fax: 619-420-1623
View Map External Link
Primary Practice Address 345 F ST STE 290
CHULA VISTA, CA 91910-2649
United States

Phone: 619-420-4523 | Fax: 619-420-1623
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice CA 50976