Healthcare Provider Details

I. General information

NPI: 1326734401
Provider Name (Legal Business Name): CRISTOBAL W GASTELUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FRANCISCO JAVIER MINA 106
TIJUANA BC
22320
MX

IV. Provider business mailing address

1267 BERYL COVE PT
SAN DIEGO CA
92154-5807
US

V. Phone/Fax

Practice location:
  • Phone: 664-252-6200
  • Fax: 619-905-1095
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. CRISTOBAL W GASTELUM
Title or Position: DENTIST
Credential: DDS
Phone: 664-252-6200