Provider Demographics
NPI:1265582258
Name:MORENO, IBAN ROEL (DDS)
Entity type:Individual
Prefix:DR
First Name:IBAN
Middle Name:ROEL
Last Name:MORENO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 BOUQUET CANYON RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1561
Mailing Address - Country:US
Mailing Address - Phone:619-397-0868
Mailing Address - Fax:
Practice Address - Street 1:1101 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2706
Practice Address - Country:US
Practice Address - Phone:619-422-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice