Provider Demographics
NPI:1295232031
Name:JOSE L SERVIN
Entity Type:Organization
Organization Name:JOSE L SERVIN
Other - Org Name:JOSE L SERVIN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:AVE OCAMPO #959
Mailing Address - Street 2:
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22000
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE OCAMPO #959
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ10041191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty