Provider Demographics
NPI:1497204028
Name:GARCIA, JOSE CARLOS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 E DOMINGUEZ ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810
Mailing Address - Country:US
Mailing Address - Phone:562-277-3407
Mailing Address - Fax:
Practice Address - Street 1:2636 E DOMINGUEZ ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810
Practice Address - Country:US
Practice Address - Phone:562-277-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86400126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86400Medicaid