Provider Demographics
NPI:1699007781
Name:TERAN, IVAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ALEXANDER
Last Name:TERAN
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 1:8775 COSTA VERDE BLVD
Mailing Address - Street 2:APT 603
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5338
Mailing Address - Country:US
Mailing Address - Phone:858-220-2476
Mailing Address - Fax:
Practice Address - Street 1:8775 COSTA VERDE BLVD
Practice Address - Street 2:APT 603
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5338
Practice Address - Country:US
Practice Address - Phone:858-220-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist