Provider Demographics
NPI:1851946495
Name:CERVANTES, VICTORIA (DMD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4891 HAIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6430
Mailing Address - Country:US
Mailing Address - Phone:831-320-8029
Mailing Address - Fax:
Practice Address - Street 1:878 EASTLAKE PKWY STE 1511
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4550
Practice Address - Country:US
Practice Address - Phone:619-739-4936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist