Provider Demographics
NPI:1346553849
Name:VIDAL CASTRO, MYRTHA DORIS (DDS)
Entity Type:Individual
Prefix:
First Name:MYRTHA
Middle Name:DORIS
Last Name:VIDAL CASTRO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12729 FOOTHILL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9334
Mailing Address - Country:US
Mailing Address - Phone:909-899-8757
Mailing Address - Fax:909-899-8760
Practice Address - Street 1:12729 FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9334
Practice Address - Country:US
Practice Address - Phone:909-899-8757
Practice Address - Fax:909-899-8760
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist