Healthcare Provider Details

I. General information

NPI: 1790374197
Provider Name (Legal Business Name): ALEJANDRO RENE MOLINA MARMOL JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 TELEGRAPH CANYON RD
CHULA VISTA CA
91910-6436
US

IV. Provider business mailing address

3975 CAMINO DE LA PLZ # 208-6189
SAN YSIDRO CA
92173-5919
US

V. Phone/Fax

Practice location:
  • Phone: 619-421-7010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number105936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: