Provider Demographics
NPI:1952647208
Name:NEW IMAGE DENTISTRY
Entity Type:Organization
Organization Name:NEW IMAGE DENTISTRY
Other - Org Name:MIRA MESA DENTAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSSANA
Authorized Official - Middle Name:TABAL
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-470-2558
Mailing Address - Street 1:819 D AVENUE, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-3465
Mailing Address - Country:US
Mailing Address - Phone:619-470-2558
Mailing Address - Fax:619-475-0799
Practice Address - Street 1:819 D AVENUE, SUITE 101
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3465
Practice Address - Country:US
Practice Address - Phone:619-470-2558
Practice Address - Fax:619-475-0799
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRA MESA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-13
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
CA49220305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013114156OtherINDIVIDUAL NPI