Provider Demographics
NPI:1801029681
Name:CLINICA DENTAL FAMILIAR SAN JUDAS TADEO
Entity Type:Organization
Organization Name:CLINICA DENTAL FAMILIAR SAN JUDAS TADEO
Other - Org Name:LOURDES CARDOSO DDS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-988-1800
Mailing Address - Street 1:1245 N GROVE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2557
Mailing Address - Country:US
Mailing Address - Phone:909-458-1068
Mailing Address - Fax:909-988-0792
Practice Address - Street 1:1245 N GROVE AVE STE C
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-2557
Practice Address - Country:US
Practice Address - Phone:909-458-1068
Practice Address - Fax:909-988-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty