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1809 National Ave San Diego CA 92113-2113 | |
| (619) 515-2300 | |
| (619) 234-2447 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 1809 National Ave, San Diego, California |
| Authorized Official Name and Position | Ricardo Roman (CFO) |
| Authorized Official Contact | 6195152300 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
823 Gateway Center Way San Diego CA 92102-4541 Ph: (619) 515-2300 | 1809 National Ave San Diego CA 92113-2113 Ph: (619) 515-2300 |
| NPI Number | 1336332725 |
|---|---|
| Provider Enumeration Date | 08/20/2007 |
| Last Update Date | 02/20/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336332725 | NPI | - | NPPES |
| CGP169666 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 090000113 (California) | Primary |
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