Healthcare Provider Details

I. General information

NPI: 1346681095
Provider Name (Legal Business Name): UNIDENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10709 MISION DE SAN JAVIER, SUITE 003
TIJUANA BAJA CALIFORNIA
22320
MX

IV. Provider business mailing address

4364 BONITA ROAD PMB 233
BONITA CA
91902-1421
US

V. Phone/Fax

Practice location:
  • Phone: 619-591-8550
  • Fax: 619-421-6632
Mailing address:
  • Phone: 619-421-6632
  • Fax: 619-421-6632

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. ERNESTO MAGANA
Title or Position: GRAL. PARTNER
Credential: D.D.S.
Phone: 619-591-8550