Provider Demographics
NPI:1396111530
Name:GARY AND MARY WEST SENIOR DENTAL CENTER, INC.
Entity type:Organization
Organization Name:GARY AND MARY WEST SENIOR DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BECERRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:760-602-5862
Mailing Address - Street 1:1525 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3107
Mailing Address - Country:US
Mailing Address - Phone:760-602-5862
Mailing Address - Fax:
Practice Address - Street 1:1525 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3107
Practice Address - Country:US
Practice Address - Phone:760-602-5862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55692261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740451012OtherINDIVIDUAL DENTAL PROVIDER NPI