Provider Demographics
NPI:1710155973
Name:CHARLES A MASTROVICH, DDS, APC
Entity Type:Organization
Organization Name:CHARLES A MASTROVICH, DDS, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:MASTROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:760-741-6650
Mailing Address - Street 1:911 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3434
Mailing Address - Country:US
Mailing Address - Phone:760-741-6650
Mailing Address - Fax:760-746-2008
Practice Address - Street 1:911 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3434
Practice Address - Country:US
Practice Address - Phone:760-741-6650
Practice Address - Fax:760-746-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty