Provider Demographics
NPI:1952820383
Name:MYRNA CARLIN DEL OLIVAR
Entity Type:Organization
Organization Name:MYRNA CARLIN DEL OLIVAR
Other - Org Name:MYRNA CARLIN D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLIN DEL OLIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:SANTA ROSALIA 20380
Practice Address - Street 2:STE 3
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22207
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1298981122300000X
ZZ691089441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty