Provider Demographics
NPI:1477799799
Name:CDM DENTAL CORP
Entity Type:Organization
Organization Name:CDM DENTAL CORP
Other - Org Name:CORONA DEL MAR DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:AGUILERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-675-3131
Mailing Address - Street 1:2345 E COAST HWY STE C
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2034
Mailing Address - Country:US
Mailing Address - Phone:949-675-3131
Mailing Address - Fax:949-675-3112
Practice Address - Street 1:2345 E COAST HWY STE C
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2034
Practice Address - Country:US
Practice Address - Phone:949-675-3131
Practice Address - Fax:949-675-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25114305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization