Healthcare Provider Details

I. General information

NPI: 1841868338
Provider Name (Legal Business Name): JOSE ALFONSO BRAVO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD UNIVERSIDAD HUETAMO 487
TECATE BAJA CALIFORNIA
21460
MX

IV. Provider business mailing address

PO BOX 369
TECATE CA
91980-0369
US

V. Phone/Fax

Practice location:
  • Phone: 619-272-9021
  • Fax: 619-272-9021
Mailing address:
  • Phone: 619-272-9021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSE ALFONSO BRAVO
Title or Position: DENTIST
Credential: DDS
Phone: 619-272-9021