Provider Demographics
NPI:1043402019
Name:GERONIMO, JORGE LUIS (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 W LINCOLN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6545
Mailing Address - Country:US
Mailing Address - Phone:714-224-0240
Mailing Address - Fax:
Practice Address - Street 1:2270 W LINCOLN AVE STE A
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-6545
Practice Address - Country:US
Practice Address - Phone:714-224-0240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice