Provider Demographics
NPI:1003356841
Name:FERNANDO CALISAYA
Entity Type:Organization
Organization Name:FERNANDO CALISAYA
Other - Org Name:FERNANDO CALISAYA DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALISAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:555-687-0414
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-727-6924
Practice Address - Street 1:1 GONZALEZ DE COSIO
Practice Address - Street 2:STE 103 COLONIA DEL VALLE
Practice Address - City:MEXICO CITY
Practice Address - State:MEXICO CITY
Practice Address - Zip Code:03100
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5129020122300000X
ZZ58508611223S0112X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty