Provider Demographics
NPI:1841868338
Name:JOSE ALFONSO BRAVO
Entity type:Organization
Organization Name:JOSE ALFONSO BRAVO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ALFONSO
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-272-9021
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:TECATE
Mailing Address - State:CA
Mailing Address - Zip Code:91980-0369
Mailing Address - Country:US
Mailing Address - Phone:619-272-9021
Mailing Address - Fax:
Practice Address - Street 1:BLVD UNIVERSIDAD
Practice Address - Street 2:HUETAMO 487
Practice Address - City:TECATE
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21460
Practice Address - Country:MX
Practice Address - Phone:619-272-9021
Practice Address - Fax:619-272-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-11
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty