1356891329 NPI number — GRISELDA GONZALEZ GRANADOS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356891329 NPI number — GRISELDA GONZALEZ GRANADOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRISELDA GONZALEZ GRANADOS
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:
6
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:
1356891329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
AVE. JUAN DE LA BARRERA # 610
Provider Second Line Business Mailing Address:
COL. PROHOGAR
Provider Business Mailing Address City Name:
MEXICALI
Provider Business Mailing Address State Name:
BAJA CALIFORNIA
Provider Business Mailing Address Postal Code:
21240
Provider Business Mailing Address Country Code:
MX
Provider Business Mailing Address Telephone Number:
011526865656591
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 EXECUTIVE SQ STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-743-3900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONZALEZ GRANADOS
Authorized Official First Name:
GRISELDA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIAT
Authorized Official Telephone Number:
800-743-3900

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2172627 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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