1265809065 NPI number — JORGE L. GERONIMO, DDS PROF. DENTAL CORP.

Table of content: (NPI 1265809065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265809065 NPI number — JORGE L. GERONIMO, DDS PROF. DENTAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORGE L. GERONIMO, DDS PROF. DENTAL CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265809065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9720 MAGNOLIA AVE SUITE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-3663
Provider Business Mailing Address Fax Number:
951-696-3887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9720 MAGNOLIA AVE SUITE #100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-696-3663
Provider Business Practice Location Address Fax Number:
951-696-3887
Provider Enumeration Date:
08/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GERONIMO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
714-267-6400

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  47897 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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