Provider Demographics
NPI:1972209641
Name:MARIANGELA GONZALEZ MIRABAL
Entity Type:Organization
Organization Name:MARIANGELA GONZALEZ MIRABAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANGELA
Authorized Official - Middle Name:GONZALEZ
Authorized Official - Last Name:MIRABAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-272-9021
Mailing Address - Street 1:505 ISLAND BREEZE LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLVD. GUSTAVO DIAZ ORDAZ 14901
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22106
Practice Address - Country:MX
Practice Address - Phone:619-272-9021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty