Provider Demographics
NPI:1356716203
Name:ORTHODONTIC AND DENTAL CLINIC
Entity type:Organization
Organization Name:ORTHODONTIC AND DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:VENEGAS RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-890-4142
Mailing Address - Street 1:477 CESAR CHAVEZ BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2129
Mailing Address - Country:US
Mailing Address - Phone:760-890-4142
Mailing Address - Fax:
Practice Address - Street 1:AVE JUSTO SIERRA # 26 LOCAL 12-A C.C. LA PLAZITA
Practice Address - Street 2:
Practice Address - City:MEXICALI
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21200
Practice Address - Country:MX
Practice Address - Phone:686-565-6710
Practice Address - Fax:686-565-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental