Provider Demographics
NPI:1427599562
Name:NEVAREZ CORRAL, JAVIER (DDS)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:NEVAREZ CORRAL
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 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:CALLE 3A CARRILLO PUERTO # 8187
Practice Address - Street 2:ZONA CENTRO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:664-357-7680
Practice Address - Fax:866-272-6924
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ566001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist