Provider Demographics
NPI:1356690184
Name:MARIO PURECO, D.D.S.,INC.
Entity Type:Organization
Organization Name:MARIO PURECO, D.D.S.,INC.
Other - Org Name:GAREY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PURECO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-469-6485
Mailing Address - Street 1:1541 S GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5222
Mailing Address - Country:US
Mailing Address - Phone:909-469-6485
Mailing Address - Fax:909-784-1378
Practice Address - Street 1:1541 S GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5222
Practice Address - Country:US
Practice Address - Phone:909-469-6485
Practice Address - Fax:909-784-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA586251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty