Provider Demographics
NPI:1275932188
Name:CASTILLO, JOSE CARLOS (DDS, MA, MMSC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:CARLOS
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:DDS, MA, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 FIFTH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5910
Mailing Address - Country:US
Mailing Address - Phone:619-295-2288
Mailing Address - Fax:
Practice Address - Street 1:2918 FIFTH AVE STE 310
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5910
Practice Address - Country:US
Practice Address - Phone:619-295-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856699122300000X
CADDS1013381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty