Provider Demographics
NPI:1457877680
Name:MARIO J. CRISTERNA DIAZ
Entity Type:Organization
Organization Name:MARIO J. CRISTERNA DIAZ
Other - Org Name:MARIO J. CRISTERNA D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISTERNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:INSURGENTES 910-B
Practice Address - Street 2:FRACC MARIAFERNANDA
Practice Address - City:MAZATLAN
Practice Address - State:SINALOA
Practice Address - Zip Code:82147
Practice Address - Country:MX
Practice Address - Phone:669-992-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6581415122300000X
090518101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty