Provider Demographics
NPI:1578014569
Name:CASTILLO, RADAMES (DDS)
Entity Type:Individual
Prefix:
First Name:RADAMES
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:800-743-3900
Mailing Address - Fax:
Practice Address - Street 1:CALZADA MONTERREY 101 LOCAL A
Practice Address - Street 2:COL. INDUSTRIAL SONORA
Practice Address - City:SAN LUIS RIO COLORADO
Practice Address - State:SONORA
Practice Address - Zip Code:83430
Practice Address - Country:MX
Practice Address - Phone:653-518-2047
Practice Address - Fax:866-272-6924
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5053975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist