1376056028 NPI number — MARIA ALCANTAR GOMEZ

Table of content: (NPI 1376056028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376056028 NPI number — MARIA ALCANTAR GOMEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIA ALCANTAR GOMEZ
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:
MARIA ALCANTAR GOMEZ DDS
Provider Other Organization Name Type Code:
3
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:
1376056028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQUARE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-488-3200
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MONTE JARAGUAY # 18701-16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIJUANA
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
22000
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
664-685-9032
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALCANTAR GOMEZ
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
619-488-3200

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  701117 , 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)