Provider Demographics
NPI:1932610656
Name:CARBAJAL, JOSE D (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:D
Last Name:CARBAJAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:SUITE 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:PASEO DE LOS HEROES #10231-205
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:664-634-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ6821315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist