Provider Demographics
NPI:1013364298
Name:SURE MEDICAL AND DENTAL CENTER SC
Entity Type:Organization
Organization Name:SURE MEDICAL AND DENTAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:PASTRANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-421-6632
Mailing Address - Street 1:4364 BONITA RD # 233
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:619-421-6632
Mailing Address - Fax:866-864-5572
Practice Address - Street 1:FRANCISCO JAVIER MINA #1571
Practice Address - Street 2:103
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:01152664-634-1114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ4211776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4211776OtherSECRETARIA DE EDUCACION PUBLICA, MEXICO