Provider Demographics
NPI:1326381450
Name:PACIFIC DENTAL CLINIC
Entity type:Organization
Organization Name:PACIFIC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GERONIMO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-924-6370
Mailing Address - Street 1:25025 RED MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551
Mailing Address - Country:US
Mailing Address - Phone:951-924-6370
Mailing Address - Fax:951-924-6374
Practice Address - Street 1:25025 RED MAPLE LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1137
Practice Address - Country:US
Practice Address - Phone:951-924-6370
Practice Address - Fax:951-924-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty