Provider Demographics
NPI:1730647769
Name:DENTAL LIFE
Entity Type:Organization
Organization Name:DENTAL LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ODONTOLOGY & DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:JAUREGUI LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-313-1494
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85628-0243
Mailing Address - Country:US
Mailing Address - Phone:520-313-1494
Mailing Address - Fax:
Practice Address - Street 1:CALLE MIGUEL IDALFO Y COSTILLA
Practice Address - Street 2:NO. 65 COL. FUNDO LEGAL
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84030
Practice Address - Country:MX
Practice Address - Phone:520-313-1494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty