Provider Demographics
NPI:1407903487
Name:CRISOSTOMO-REYES, AUREA BALLAT (DMD)
Entity Type:Individual
Prefix:DR
First Name:AUREA
Middle Name:BALLAT
Last Name:CRISOSTOMO-REYES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11633 WINDING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-6158
Mailing Address - Country:US
Mailing Address - Phone:858-578-2912
Mailing Address - Fax:
Practice Address - Street 1:9844 HIBERT ST
Practice Address - Street 2:SUITE G-7
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1000
Practice Address - Country:US
Practice Address - Phone:858-271-7440
Practice Address - Fax:858-271-0180
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice