Provider Demographics
NPI:1558550525
Name:OSVALDO R. GARCIA D.D.S. A DENTAL CORPORATION
Entity Type:Organization
Organization Name:OSVALDO R. GARCIA D.D.S. A DENTAL CORPORATION
Other - Org Name:WATERMAN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:R
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-889-1111
Mailing Address - Street 1:1428 N WATERMAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5382
Mailing Address - Country:US
Mailing Address - Phone:909-889-1111
Mailing Address - Fax:909-386-3667
Practice Address - Street 1:1428 N WATERMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5382
Practice Address - Country:US
Practice Address - Phone:909-889-1111
Practice Address - Fax:909-386-3667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32460-01Medicaid