Provider Demographics
NPI:1982893087
Name:FABRIEL D BURQUEZ
Entity Type:Organization
Organization Name:FABRIEL D BURQUEZ
Other - Org Name:FABRIEL D BURQUEZ DDS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:FABRIEL
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:BURQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-479-4457
Mailing Address - Street 1:180 OTAY LAKES RD STE 210B
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2400
Mailing Address - Country:US
Mailing Address - Phone:619-479-4457
Mailing Address - Fax:619-479-4827
Practice Address - Street 1:180 OTAY LAKES RD STE 210B
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2400
Practice Address - Country:US
Practice Address - Phone:619-479-4457
Practice Address - Fax:619-479-4827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49476261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG89774-01OtherDENTICAL