Provider Demographics
NPI:1194374439
Name:ENCISO, JORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:ENCISO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:
Other - Last Name:ENCISO-CARMONA
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13554 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-5517
Mailing Address - Country:US
Mailing Address - Phone:909-910-5824
Mailing Address - Fax:
Practice Address - Street 1:10683 MAGNOLIA AVE STE D
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1893
Practice Address - Country:US
Practice Address - Phone:951-324-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1040371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice