Provider Demographics
NPI:1033488663
Name:AMERICAN BIODENTAL CENTER
Entity Type:Organization
Organization Name:AMERICAN BIODENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:PERLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1877-231-5701
Mailing Address - Street 1:PO BOX 210116
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91921-0116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4558 AGUA CALIENTE BLVD
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BC
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:664-686-1158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ8746001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty