Provider Demographics
NPI:1558835496
Name:CARLOS FERNANDO DENTAL CORPORATION
Entity Type:Organization
Organization Name:CARLOS FERNANDO DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-856-7135
Mailing Address - Street 1:9151 ATLANTA AVE UNIT 7891
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-2613
Mailing Address - Country:US
Mailing Address - Phone:714-856-7135
Mailing Address - Fax:714-960-3309
Practice Address - Street 1:999 N TUSTIN AVE STE 9&10
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3528
Practice Address - Country:US
Practice Address - Phone:714-856-7135
Practice Address - Fax:714-960-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental