Provider Demographics
NPI:1457526568
Name:ALFONSO, IDA DELOS SANTOS
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:DELOS SANTOS
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5814 VAN ALLEN WAY
Mailing Address - Street 2:SUITE #205
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:760-931-0144
Mailing Address - Fax:760-931-0827
Practice Address - Street 1:5814 VAN ALLEN WAY STE 205
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7360
Practice Address - Country:US
Practice Address - Phone:760-931-0144
Practice Address - Fax:760-931-0827
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice