Provider Demographics
NPI:1376767038
Name:CERVANTES, RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2387 US HIGHWAY 86
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9780
Mailing Address - Country:US
Mailing Address - Phone:760-353-5100
Mailing Address - Fax:760-353-0576
Practice Address - Street 1:2387 US HIGHWAY 86
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9780
Practice Address - Country:US
Practice Address - Phone:760-353-5100
Practice Address - Fax:760-353-0576
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34071-2OtherDELTA
CA34071OtherDENTAL BOARD
CA34071-1OtherDELTA