Provider Demographics
NPI:1154838605
Name:EDGAR E. AQUINO BRAVO
Entity Type:Organization
Organization Name:EDGAR E. AQUINO BRAVO
Other - Org Name:EDGAR E. AQUINO BRAVO D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:E
Authorized Official - Last Name:AQUINO BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
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:866-272-6924
Practice Address - Street 1:COL. LA FUENTE
Practice Address - Street 2:C. LA FUENTE 1-12
Practice Address - City:TIJUANA
Practice Address - State:B.C.
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:661-114-6716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ6098765122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty