Provider Demographics
NPI:1255470803
Name:JEBCOB
Entity Type:Organization
Organization Name:JEBCOB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPARZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-984-3618
Mailing Address - Street 1:527 N PALM AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3215
Mailing Address - Country:US
Mailing Address - Phone:909-984-3618
Mailing Address - Fax:909-984-9479
Practice Address - Street 1:527 N PALM AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3215
Practice Address - Country:US
Practice Address - Phone:909-984-3618
Practice Address - Fax:909-984-9479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41648122300000X
CA45252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10442-1OtherBLUE SHIELD
CAD45252--01Medicaid
CA828309OtherUNITED CONCORDIA
CAB41648-01Medicaid