Provider Demographics
NPI:1457503922
Name:CLINICA DENTAL INTEGRAL
Entity Type:Organization
Organization Name:CLINICA DENTAL INTEGRAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-270-2243
Mailing Address - Street 1:9379 IGNACIO COMONFORT
Mailing Address - Street 2:SUITE 'B'
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22210
Mailing Address - Country:MX
Mailing Address - Phone:619-270-2243
Mailing Address - Fax:
Practice Address - Street 1:3045 S ARCHIBALD AVE
Practice Address - Street 2:SUITE H-289
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-9001
Practice Address - Country:US
Practice Address - Phone:909-758-8275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMEXUS DENTAL PPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZMX157931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty