1770148728 NPI number — CITRACADO DENTAL GROUP

Table of content: (NPI 1770148728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770148728 NPI number — CITRACADO DENTAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITRACADO DENTAL GROUP
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:
1770148728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W EL NORTE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESCONDIDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92026-3983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-489-5545
Provider Business Mailing Address Fax Number:
760-489-5546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W EL NORTE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92026-3983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-489-5545
Provider Business Practice Location Address Fax Number:
760-489-5546
Provider Enumeration Date:
05/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JUNGMAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER DENTIST
Authorized Official Telephone Number:
760-489-5545

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1265653828 . This is a "NPPES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1841330198 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1902156367 . This is a "NPPES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1194124867 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1558582247 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1356562821 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".




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